Alternative specimen extraction techniques after laparoscopic emergency colectomy in inflammatory bowel disease

Background  

Omitting the extraction site incision potentially further decreases the abdominal wall trauma in laparoscopic surgery. The purpose of this study was to report the results of alternative specimen extraction techniques after laparoscopic emergency colectomy in patients with inflammatory bowel disease (IBD).     

Assessment of thoracic aortic dimensions in an experimental setting: comparison of different unenhanced magnetic resonance angiography techniques with electrocardiogram-gated computed tomography angiography for possible application in the pediatric population

PURPOSE: To compare different unenhanced magnetic resonance angiography (MRA) techniques for quantitative evaluation of vessel lumen in an experimental setting in young pigs whose dimensions allow for a comparison with a pediatric population. MATERIAL AND METHODS: Magnetic resonance imaging was performed in 5 healthy ventilated pigs at 1.5 T. Three different electrocardiogram (ECG)-triggered sequences were applied for MRA: [TSE-Db] T2-weighted dark-blood TurboSpinEcho (2.0 x 1.1 x 4 mm3); [trueFISP] 2D-steady-state-free-precession (2.2 x 1.8 x 2 mm3); [NAV] respiratory-gated, T2-prepared 3D-trueFISP (1.3 x 1.3 x 1.3 mm3). ECG-gated-CT angiography (CTA) (16-row CT, 1 mm collimation) served as the standard of reference. The vessel lumen was measured at 7 positions perpendicularly angulated to the vessel wall on multiplanar reformations: ascending aorta (P1), the aortic arch before (P2) and after (P3) the origin of the first supraaortic branch, the aortic arch after the origin of the second supraaortic branch (P4), the descending aorta at the level of the diaphragm (P5), and the first and second supraaortic branches (P6, P7). RESULTS: Percentage differences in the vessel area determined by MRA reformation compared with CTA-reformation were 10% +/- 20% and 35% +/- 27% (TSE-Db), -4% +/- 13% and 20% +/- 24% (trueFISP), and -3% +/- 13% and -10% +/- 19% (NAV), for positions P1 to P5 and P6 to P7, respectively. A significant difference from CTA was found for TSE-Db at all positions, and for trueFISP only at positions P6 and P7. CONCLUSIONS: Unenhanced MRA techniques allow for a reliable assessment of the dimensions of the thoracic aorta compared with CTA as the standard of reference. Using ECG-gating and navigator techniques, the free-breathing approach showed the best agreement with CTA. This technique may therefore be the most useful in the pediatric age group allowing for true 3D data acquisition with its inherent postprocessing possibilities.     

Oxyntic mucosa pseudopolyps: a presentation of atrophic autoimmune gastritis

Gastric polyps are often present in the setting of atrophic gastritis. Although the majority of these polyps are nonneoplastic, such as hyperplastic polyps, neoplastic polyps may be present. We discuss nine cases that illustrate an additional nonneoplastic cause of polyps in atrophic gastritis. Specifically, preserved islands of relatively normal oxyntic mucosa in a background of gastric atrophy may appear polypoid endoscopically. The patients (seven women, two men, mean age 64 years) presented with nonspecific abdominal or reflux symptoms (n = 8) and diarrhea (n = 1). Five of five patients tested were confirmed to have hypergastrinemia, and three of three patients tested had antiparietal cell antibodies. Biopsies from the gastric body or fundus of our nine patients showed fragments of atrophic mucosa and separate fragments of preserved oxyntic mucosa. Based upon the histologic characteristics of the atrophic fundic and relatively normal antral biopsies, the gastric atrophy appeared to be of autoimmune-type. The relatively preserved oxyntic glands showed parietal cell hypertrophy and focal mild chronic inflammation. The number of polyps observed endoscopically ranged from less than five to multiple/diffuse. Three patients had persistent nodularities in their stomachs for 1, 3, and 7 years of their follow-up. Our study shows that some patients with atrophic gastritis, autoimmune-type, may present with gastric polyps/nodules that represent relatively preserved oxyntic mucosa. This presentation may be more common than is presently recognized because biopsies of the polyps alone will not show histologic features of atrophic gastritis or reveal the etiology of the polyp itself. Although a limited number of previous studies have suggested this type of polypoid presentation may represent "early" atrophic gastritis, its persistence in three of our patients argues against this hypothesis.     

A cause for conversion of laparoscopic splenectomy: splenic candidiasis

Laparoscopic splenectomy (LS) is now considered the procedure of choice for removal of the spleen in several hematologic and traumatic splenic conditions. Perisplenitis is still considered a relative contraindication. We report a rare case of isolated splenic candidiasis treated by laparoscopic splenectomy. The technical challenges of the laparoscopic approach in cases of perisplenitis are outlined. Because of dense adhesions to the diaphragm, the LS was converted to open splenectomy, and the procedure was completed through a small subcostal incision. This case report suggests the need for and effectiveness of splenectomy in patients whose fungal infection is suspected to be localized to the spleen. Laparoscopic removal of the spleen in these cases is very difficult to accomplish because of the risk for diaphragm injuries and the technical problems encountered.     

Haploinsufficiency of Pkd2 is associated with increased tubular cell proliferation and interstitial fibrosis in two murine Pkd2 models.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited human kidney disease and is caused by germline mutations in PKD1 (85%) or PKD2 (15%). It has been estimated that around 1% of tubular cells give rise to cysts, and cell hyperproliferation has been noted to be a cardinal feature of cystic epithelium. Nevertheless, it is uncertain whether the increase in proliferative index observed is an early or late feature of the cystic ADPKD kidney. METHODS: Two Pkd2 mouse mutants (WS25 and WS183) have been recently generated as orthologous models of PKD2. To determine the effect of Pkd2 dosage on cell proliferation, cyst formation and renal fibrosis, we studied renal tissue from Pkd2(WS25/WS25) and Pkd2(+/-) mice by histological analysis. We also examined the proliferative index in archival nephrectomy tissue obtained from patients with ADPKD and normal controls. RESULTS: The proliferative index of non-cystic tubules in Pkd2 mutant mice as assessed by proliferating cell nuclear antigen and Ki67-positive nuclei was between 1-2%, values 5-10 times higher than control tissue. Similarly, the proliferative index of non-cystic tubules in human ADPKD kidneys was 40 times higher than corresponding controls. In Pkd2 mutant mice, significant correlations were found between the fibrosis score and the mean cyst area as well as with the proliferative index. Of significance, proliferating tubular cells were uniformly positive for polycystin-2 expression in Pkd2(+/-) kidney. CONCLUSION: These results suggest that an increase in cell proliferation is an early event preceding cyst formation and can result from haploinsufficiency at Pkd2. The possible pathogenic link between tubular cell proliferation, interstitial fibrosis and cyst formation is discussed.     

Hearing loss alters the subcellular distribution of presynaptic GAD and postsynaptic GABAA receptors in the auditory cortex

We have shown previously that auditory experience regulates the maturation of excitatory synapses in the auditory cortex (ACx). In this study, we used electron microscopic immunocytochemistry to determine whether the heightened excitability of the ACx following neonatal sensorineural hearing loss (SNHL) also involves pre- or postsynaptic alterations of GABAergic synapses. SNHL was induced in gerbils just prior to the onset of hearing (postnatal day 10). At P17, the gamma-aminobutyri acid type A (GABA(A)) receptor's beta2/3-subunit (GABA(A)beta2/3) clusters residing at plasma membranes in layers 2/3 of ACx was reduced significantly in size (P < 0.05) and number (P < 0.005), whereas the overall number of immunoreactive puncta (intracellular + plasmalemmal) remained unchanged. The reduction of GABA(A)beta2/3 was observed along perikaryal plasma membranes of excitatory neurons but not of GABAergic interneurons. This cell-specific change can contribute to the enhanced excitability of SNHL ACx. Presynaptically, GABAergic axon terminals were significantly larger but less numerous and contained 47% greater density of glutamic acid decarboxylase immunoreactivity (P < 0.05). This suggests that GABA synthesis may be upregulated by a retrograde signal arising from lowered levels of postsynaptic GABA(A)R. Thus, both, the pre- and postsynaptic sides of inhibitory synapses that form upon pyramidal neurons of the ACx are regulated by neonatal auditory experience.     

Noise pollution on an acute surgical ward

INTRODUCTION

This study was undertaken to measure and analyse noise levels over a 24-h period on five general surgical wards.

PATIENTS AND METHODS

Noise levels were measured on three wards with four bays of six beds each (wards A, B and C), one ward of side-rooms only (ward D) and a surgical high dependency unit (ward E) of eight beds. Noise levels were measured for 15 min at 4-hourly intervals over a period of 24 h midweek. The maximum sound pressure level, baseline sound pressure level and the equivalent continuous level (LEq) were recorded. Peak levels and LEq were compared with World Health Organization (WHO) guidelines for community noise. Control measurements were taken elsewhere in the hospital and at a variety of public places for comparison.

RESULTS

The highest peak noise level recorded was 95.6 dB on ward E, a level comparable to a heavy truck. This exceeded all control peak readings except that recorded at the bus stop. Peak readings frequently exceeded 80 dB during the day on all wards. Each ward had at least one measurement which exceeded the peak sound level of 82.5 dB recorded in the supermarket. The highest peak measurements on wards A, B, C and E also exceeded peak readings at the hospital main entrance (83.4 dB) and coffee shop (83.4 dB). Ward E had the highest mean peak reading during the day and at night – 83.45 dB and 81.0 dB, respectively. Ward D, the ward of side-rooms, had the lowest day-time mean LEq (55.9 dB). Analysis of the LEq results showed that readings on ward E were significantly higher than readings on wards A, B and C as a group (P = 0.001). LEq readings on ward E were also significantly higher than readings on ward D (P < 0.001). Day and night levels differ significantly, but least so on the high dependency unit.

CONCLUSIONS

The WHO guidelines state that noise levels on wards should not exceed 30 dB LEq (day and night) and that peak noise levels at night should not exceed 40 dB. Our results exceed these guidelines at all times. It is likely that these findings will translate to other hospitals. Urgent measures are needed to rectify this.     

Platelet Cyclic Guanosine Monophosphate as a Biomarker of Phosphodiesterase Type 5 Inhibitor Efficacy in the Treatment of Erectile Dysfunction: A Randomized Placebo-Controlled Study

Background

Phosphodiesterase 5 inhibitors (PDE5-Is) are a mainstay in the therapy of erectile dysfunction (ED). The primary end point of clinical efficacy, both in clinical studies and normal practice, is represented by the International Index of Erectile Function (IIEF).

Objective

To evaluate if platelet cyclic guanosine monophosphate (cGMP) could represent a valuable marker for PDE5-I activity in ED.

Design, setting, and participants

The study enrolled 46 patients with psychogenic, organic, and mixed ED (20–71 yr of age; IIEF score <26). Patients were randomized to 6 wk of vardenafil, 5 mg/d at bedtime, or placebo.

Intervention

All patients donated two blood samples, one before starting the protocol and the second after 6 wk of treatment.

Measurements

Platelet cGMP was measured in both placebo and vardenafil groups. All the patients completed the IIEF-Erectile Function (EF) domain and the sexual encounter profile (SEP) and underwent visual sexual stimulation (VSS) coupled with Rigiscan. All the measurements were performed prior to starting the protocol and after the 6 wk of treatment.

Results and limitations

Platelet cGMP production was significantly (p < 0.05) elevated in patients taking 5 mg vardenafil versus placebo. Vardenafil was not superior to placebo in improving IIEF-EF and SEP scores. Conversely, VSS-Rigiscan revealed a significant amelioration (p < 0.028) in the vardenafil group versus placebo. The changes in platelet cGMP level correlated well with VSS-Rigiscan (p = 0.0037) but not with IIEF-EF and SEP.

Conclusions

Platelet cGMP could represent a relatively simple, reliable, and objective biomarker of PDE5-I activity in ED clinical studies. Larger clinical studies are needed to further validate the use, utility, and limits of this assay.