Management of recurrent rectal prolapse

PURPOSE: Many operations have been described for the management of rectal prolapse. Despite an overall recurrence rate of greater than 15 percent, few reviews address how to deal with this problem. This report summarizes our experience with recurrent rectal prolapse and includes suggestions for reoperative management of failed repairs from both abdominal and perineal approaches. PATIENTS AND METHODS: Fourteen patients (3 male) ranging in age from 22 to 92 (mean, 68) years underwent operative correction of recurrent rectal prolapse. Average time from initial operation to recurrence was 14 (range, 6–60) months. Initial operations (before recurrence) were as follows: perineal proctectomy and levatorplasty (10), anal encirclement (2), Delorme's procedure (1), and anterior resection (1). Operative procedures performed for recurrence were as follows: perineal proctectomy and levatorplasty (7), sacral rectopexy (abdominal approach; 3), anterior resection with rectopexy (2), Delorme's procedure (1), and anal encirclement (1). Average length of follow-up was 50 (range, 9–115) months. RESULTS: No further episodes of complete rectal prolapse were observed during this period. Preoperatively, three patients were noted to be incontinent to the extent that necessitated the use of perineal pads. The reoperative procedures failed to restore fecal continence in any of these three individuals. One patient died in the postoperative period after anal encirclement from an unrelated cause. CONCLUSION: Surgical management of recurrent rectal prolapse can be expected to alleviate the prolapse, but not necessarily fecal incontinence. Perineal proctectomies can be safely repeated. Resectional procedures may result in an ischemic segment between two anastomoses, unless the surgeon can resect a previous anastomosis in the repeat procedure. Nonresectional procedures such as the Delorme's procedure should be strongly considered in the management of recurrent rectal prolapse if a resectional procedure was performed initially and failed.     

Superior rectal artery origin from the median sacral artery—angiographic appearance,developmental anatomy,and clinical implications

Two angiographic observations of significant rectal vascularization by branches originating from the median sacral artery (MSA) are reported. In the first case, the MSA provided a complete superior rectal trunk, with left and right branches, while in the second, the MSA only contributed superior rectal branches to the right side of the rectum, the left side being supplied by left internal iliac branches. The angiographic appearance, developmental anatomy, and clinical significance of these variants are discussed. Clin. Anat. 27:900–905, 2014. © 2014 Wiley Periodicals, Inc.     

Evaluation of BBL CHROMagar VanRE for Detection of Vancomycin-Resistant Enterococci in Rectal Swab Specimens

A study was performed on 517 surveillance rectal swabs to evaluate a selective and differential chromogenic medium, the BBL CHROMagar VanRE (CVRE), which enables recovery and identification of VanA- and VanB-containing Enterococcus faecium (ENFM) and Enterococcus faecalis (ENFS) isolates. Compared to BBL Enterococcosel agar, a bile-esculin-azide-vancomycin (BEAV) agar, the initial overall sensitivity, specificity, and positive and negative predictive values of CVRE for the detection of vancomycin-resistant ENFM and ENFS were 99.1% and 94.8% and 84.2% and 99.7%, respectively. Among our patient population, more vancomycin-resistant enterococci (VRE) were recovered with CVRE than BEAV.Vancomycin-resistant enterococci (VRE) are major causes of nosocomial infections in health care facilities, and those patients infected with VRE have worse outcomes while hospitalized (8). Rapid, reliable identification of these antibiotic-resistant organisms is crucial for patient management and infection control measures (9, 12).Culture from rectal swabs or stool specimens onto bile-esculin-azide agar with vancomycin (BEAV) is the VRE screening method used in many clinical laboratories. Confirmation of VRE using this medium requires 48 to 72 h. Chromogenic agars to detect VRE demonstrate promise (1-7, 10). BBL CHROMagar VanRE (CVRE; BD Diagnostics, Sparks, MD) is a selective and differential chromogenic agar under development for the detection of vancomycin-resistant E. faecium (VRENFM) and vancomycin-resistant Enterococcus faecalis (VRENFS). CVRE contains 8 μg/ml of vancomycin and uses chromogenic substrates to phenotypically differentiate VRENFM as mauve colonies and VRENFS as green colonies. Other bacteria are inhibited or typically grow as a color other than mauve or green. Our study compared the clinical performance of CVRE with that of BEAV for primary isolation and detection of VRE from surveillance rectal swabs.     

Restricted Arp3 expression in the testis prevents blood–testis barrier disruption during junction restructuring at spermatogenesis

In epithelia, a primary damage of tight junctions (TJ) always leads to a secondary disruption of adherens junction (AJ), and vice versa. This response, if occurring in the testis, would disrupt spermatogenesis because the blood–testis barrier (BTB) must remain intact during the transit of spermatids in the seminiferous epithelium, which is associated with extensive apical ectoplasmic specialization (apical ES, a testis-specific AJ type) restructuring. As such, apical ES restructuring accompanied with the transit of developing spermatids during spermiogenesis must be segregated from the BTB to avoid an immunological barrier breakdown in all stages of the seminiferous epithelial cycle, except at stage VIII when spermiation and BTB restructuring take place concurrently. We report herein a mechanism involving restricted spatial and temporal expression of Arp2/3 complex and N-WASP, whose actin branching activity associated with apical ES and BTB restructuring in the seminiferous epithelium. High expression of Arp3 at the apical ES was shown to correlate with spermatid movement and proper spermatid orientation. Likewise, high Arp3 level at the BTB associated with its restructuring to accommodate the transit of preleptotene spermatocytes at stage VIII of the epithelial cycle. These findings were validated by in vitro and in vivo studies using wiskostatin, an inhibitor that blocks N-WASP from activating Arp2/3 complex to elicit actin branching. Inhibition of actin branching caused a failure of spermatid transit plus a loss of proper orientation in the epithelium, and a “tightened” Sertoli cell TJ permeability barrier, supporting the role of Arp2/3 complex in segregating the events of AJ and BTB restructuring.     

Gene3D: structural assignment for whole genes and genomes using the CATH domain structure database

We present a novel web-based resource, Gene3D, of precalculated structural assignments to gene sequences and whole genomes. This resource assigns structural domains from the CATH database to whole genes and links these to their curated functional and structural annotations within the CATH domain structure database, the functional Dictionary of Homologous Superfamilies (DHS) and PDBsum. Currently Gene3D provides annotation for 36 complete genomes (two eukaryotes, six archaea, and 28 bacteria). On average, between 30% and 40% of the genes of a given genome can be structurally annotated. Matches to structural domains are found using the profile-based method (PSI-BLAST). and a novel protocol, DRange, is used to resolve conflicts in matches involving different homologous superfamilies.     

Temsirolimus with or without megestrol acetate and tamoxifen for endometrial cancer: A gynecologic oncology group study

Objectives

To determine the response, toxicities, and progression free survival of a regimen of temsirolimus with or without hormonal therapy in the treatment of advanced, or recurrent endometrial carcinoma.

Background

Preclinical evidence suggested that blockade of the PI3K/AKT/mTOR pathway might overcome resistance to hormonal therapy.

Methods

We performed a randomized phase II trial of intravenous temsirolimus 25 mg weekly versus the combination of weekly temsirolimus with a regimen of megestrol acetate 80 mg bid for three weeks alternating with tamoxifen 20 mg bid for three weeks in women with recurrent or metastatic endometrial carcinoma.

Results

There were 71 eligible patients who received at least one dose of therapy with 21 of these treated on the combination arm which was closed early because of an excess of venous thrombosis, with 5 episodes of deep venous thrombosis (DVT) and 2 pulmonary emboli. There were three responses observed in that arm (14%). A total of 50 eligible patients were treated on the single agent arm with 3 episodes of DVT and 11 responses (22%). Response rates were similar in patients with prior chemotherapy (7 of 29; 24%) and those with no prior chemotherapy (4 of 21; 19%). Two of four patients with clear cell carcinoma responded.

Conclusions

Adding the combination of megestrol acetate and tamoxifen to temsirolimus therapy did not enhance activity and the combination was associated with an excess of venous thrombosis. Temsirolimus activity was preserved in patients with prior adjuvant chemotherapy.     

Methicillin-Resistant and -Susceptible Staphylococcus aureus Infections in Dogs

Methicillin-resistant Staphylococcus aureus (MRSA) has become a pathogen of animals. To compare types of infections, clinical outcomes, and risk factors associated with MRSA in dogs with those associated with methicillin-susceptible Staphylococcus aureus (MSSA) infections, we conducted a case–control study at 3 veterinary referral hospitals in the United States and Canada during 2001–2007. Risk factors analyzed were signalment, medical and surgical history, and infection site. Among 40 dogs with MRSA and 80 with MSSA infections, highest prevalence of both infections was found in skin and ears. Although most (92.3%) dogs with MRSA infections were discharged from the hospital, we found that significant risk factors for MRSA infection were receipt of antimicrobial drugs (odds ratio [OR] 3.84, p = 0.02), β-lactams (OR 3.58, p = 0.04), or fluoroquinolones (OR 5.34, p = 0.01), and intravenous catheterization (OR 3.72, p = 0.02). Prudent use of antimicrobial drugs in veterinary hospitals is advised.