Inhibition of 11beta-hydroxysteroid dehydrogenase enzymatic activities by glycyrrhetinic acid in vivo supports direct glucocorticoid-mediated suppression of steroidogenesis in Leydig cells

Previous studies have suggested that glucocorticoid (GC) can directly affect testicular testosterone (T) biosynthesis by Leydig cells through a receptor-mediated mechanism. Interconversion of corticosterone (CORT), the active form in rodents, and 11-dehydroCORT, the biologically inert 11-keto form, is catalyzed by 11betaHSD1. This enzyme thus controls the intracellular concentration of active GC. We have postulated that elevated CORT levels resulting from stress exceed the Leydig cell's capacity for metabolic inactivation of CORT, resulting in suppressed T production. The present study tested whether inhibition of 11betaHSD1 in vivo, by the administration of glycyrrhetinic acid (GA), increases intracellular active GC concentration and thereby affects serum T concentration and Leydig cell T production. Adult Sprague-Dawley rats were treated with vehicle (corn oil), CORT, GA, or GA + CORT. Serum luteinizing hormone (LH), CORT, and T levels were measured, as were the steroidogenic capacities of purified Leydig cells. Twofold elevations of CORT were achieved by the administration of either CORT or GA alone, but in both cases there was no effect on serum T levels. However, when CORT and GA were administered in combination, serum CORT levels increased 3.5-fold (to 420 +/- 34 ng/mL) and serum T levels were reduced significantly (to 0.72 +/- 0.07 ng/mL; control, 2.12 +/- 0.23 ng/mL). Serum levels of LH were not affected by CORT, GA, or GA + CORT. Consistent with the reduced serum T levels following GA + CORT, steroidogenic enzyme expression and capacities were significantly reduced compared to control. These data support a role for 11betaHSD1 in modulating intracellular CORT concentrations and, in turn, for a direct effect of GC on Leydig cells in response to stress.     

Arthrodesing Operations on the Feet

Dr. Edwin Warner Ryerson was born in New York City, graduated from Harvard, then trained at Boston Children’s Hospital [1]. After visiting centers in Berlin and Vienna he moved to Chicago in 1899, where he accepted a post at Rush Medical College. In 1916 he was named professor and head of orthopaedics at the University of Illinois College of Medicine. Owing to WWI he entered military service in 1918–1919. Afterward he became head of orthopaedics at Northwestern University until his retirement from the university in 1935. He continued in private practice until 1947, when he retired to Florida. Dr. Ryerson maintained a lifelong interest in teaching and service to the orthopaedic community. He became a member of the American Orthopaedic Association in 1905 and was President in 1925. Dr. Ryerson was active in the Clinical Orthopaedic Society, which also had a role in forming American Academy of Orthopaedic Surgeons [4]. In the archives of the AAOS, he was described as “a forensic and parliamentary expert” [6]. He was a founding member of the American Board of Orthopaedic Surgery in 1934, became its vice President in 1935, and served on the Board until 1940 [11].     

Quality of Life After TKA for Patients With Juvenile Rheumatoid Arthritis

Total knee arthroplasty frequently is required during early adulthood in patients with advanced juvenile rheumatoid arthritis. We queried patients on issues of importance to them, asked whether they were satisfied with surgical outcomes, and ascertained their postoperative status. We retrospectively reviewed 14 adult patients (22 knees) with severe juvenile rheumatoid arthritis who were treated with primary total knee arthroplasty between 1989 and 2001. All patients were evaluated by pain and stiffness visual analog scales, range of motion, the Patient-Specific Index, Hospital for Special Surgery knee score, WOMAC Osteoarthritis Index, EuroQuol in five dimensions, and SF-36 Health Survey. Preoperative scores were assessed by recall. Patients had a minimum followup of 2 years (mean, 8 years; range, 2-13 years). Quality of life improved after TKA as measured by the Patient-Specific Index. Eighteen of 22 patients rated themselves satisfied with the functional outcome of their surgery; all patients were satisfied with pain relief. Final SF-36, EuroQuol in five dimensions, and WOMAC scores were low compared with age-matched population norms. A mean postoperative flexion arc of 77 degrees (range, 30 degrees -130 degrees ) was observed. Total knee arthroplasty had a major positive impact on quality of life as reported by patients. LEVEL OF EVIDENCE: Level IV, therapeutic study.     

Is a T-tube Necessary after Common Bile Duct Exploration?

BACKGROUND: T-tube drainage used to be standard practice after surgical choledocholithotomy, but there is now a tendency in some centers to close the common bile duct (CBD) primarily. This study was designed to review the complications associated with T-tube drainage after CBD exploration and to determine whether primary closure of the bile duct reduces postoperative morbidity. METHODS: A retrospective audit was performed on patients undergoing CBD exploration between July 1997 and March 2007, who were identified from the theatre database of one teaching hospital. Intraoperative findings and postoperative complications were recorded from the clinical notes. RESULTS: During the study period, 158 patients (97 women; median age 65 (range, 25-90) years) underwent CBD exploration. A T-tube was inserted in 91 patients (group I) and the CBD was closed primarily in 67 (group II). One or more biliary complications occurred in 26 patients (16.5%): 20 (22.0%) in group I and 6 (8.9%) in group II (p = 0.03). In group I, 15 had a biliary leak (3 needed reoperation), 2 had accidental slippage of the tube, 2 an entrapped T-tube, and 1 a retained stone. In group II, six patients had biliary leakage, two of whom were re-explored. Six patients in group I also had peritubal infection, necessitating the use of antibiotics. There were three deaths: two in group I (1 T-tube-related) and 1 in group II (p = 1, not significant). CONCLUSION: There is a lower biliary complication rate associated with primary closure of the CBD than after T-tube drainage.     

Mesh fixation using staples in Lichtenstein’s inguinal hernioplasty: fewer complications and fewer recurrences

BACKGROUND: Fixation of the mesh in Lichtenstein's inguinal hernioplasty is traditionally performed with polypropylene sutures. A modification of this technique uses staples for securing of the mesh. METHOD: A retrospective comparative study of 149 elective repairs of a primary inguinal hernia was performed: a control group of 67 patients undergoing mesh fixation using sutures and a study group of 82 patients undergoing staple fixation. Operating time, recurrence, postoperative pain, complications and costs were studied. RESULTS: Seven recurrences (11%) occurred in the polypropylene group as compared to one recurrence (1%) in the staple group (P < 0.01). There was a trend of fewer complications in the staple group. Operative time and long-term postoperative pain did not differ significantly between the two groups. The costs per surgery for mesh fixation and skin closure were 11.13 for the suture group and 24.35 for the staple group. CONCLUSION: Staple fixation of the mesh in Lichtenstein's inguinal hernioplasty can be considered equal to traditional fixation with sutures with regard to operating time and postoperative pain. However, staple fixation seems to show fewer recurrences and fewer complications.     

The reaction of posttransplant denervated liver on the hemorrhagic shock in rats

OBJECTIVE: The aims of the study were to determine the effects of denervation on the function of the liver transplantation as a blood reservoir and to define its vulnerability to ischemic-reperfusion (I/R) injury after hemorrhagic shock. MATERIALS AND METHODS: Hemorrhagic shock with a mean arterial blood pressure (MAP) of 40 to 50 mm Hg was induced by withdrawing blood at a rate of approximately 1 mL/min among 10 posttransplant denervated rats and 10 sham rats for 1 hour. The rats were then resuscitated by retransfusing the drawn blood with sacrifice under deep anesthesia at 1 hour after resuscitation. The total amount of blood required to achieve hemorrhagic shock was compared between groups as well as the vulnerability and reactions of the posttransplant denervated liver to I/R injury after hemorrhagic shock as assessed by gene expressions of c-jun, c-fos, tumor necrosis factor (TNF)-alpha, interleukin (IL)6, IL-10, and heat-shock protein 70 (HSP70). RESULTS: The volume of blood that had to be drawn to reach a MAP of 40 to 50 mm Hg was not significantly different between the groups. One hour of hemorrhagic shock followed by resuscitation resulted in significant increases in the genes expression of c-fos, TNF-alpha, IL-6, IL-10, and HSP70 in comparison to the control values, but no difference was observed between experimental and sham groups. CONCLUSION: We suggest that the function of the liver as a blood reservoir and the gene expressions of c-fos and pro- and anti-inflammatory cytokines, as well as the protective protein HSP70 in response to I/R injury, were not altered by liver transplantation.     

Inducible nitric oxide synthase expressions in different lung injury models and the protective effect of aminoguanidine

OBJECTIVE: Our aim was to study the expression of inducible nitric oxide synthase (iNOS) in 2 experimental models: (1) ischemia/reperfusion (I/R) of the lung tissues and (2) oleic acid infusion. The protective effect of an iNOS inhibitor, aminoguanidine, was evaluated in these 2 injury models. MATERIALS AND METHODS: Real-time polymerase chain reactions and Western blots were used to assess the mRNA and protein expressions of iNOS in lung tissues after applying 2 injury models. In the I/R model, ischemia was induced by clamping one branch of the pulmonary artery for 60 minutes and then reperfusing for 120 minutes. In the bone fracture model, lung injury was induced by intravenous (IV) infusion of oleic acid (0.1 mL/kg); analysis was performed 6 hours after injury. Blood samples were collected for the assay of 3 inflammatory parameters: tumor necrosis factor alpha, hydroxyl radicals, and nitric oxide (NO). The wet/dry lung weight ratio was used as a parameter reflecting the lung injury level. RESULTS: mRNA and protein expressions of iNOS were significantly increased in these 2 lung injury models compared with the controls. Blood concentrations of TNFalpha, hydroxyl radicals, NO, and wet/dry lung weight ratio were also significantly higher in the 2 experimental groups than in the sham-treated group. The iNOS inhibitor aminoguanidine (20 mg/kg) significantly attenuated the lung injury induced by these challenges. CONCLUSIONS: Reperfusion of the ischemic lung tissues or IV infusion of oleic acid can both induce lung injury by activating systemic inflammatory responses and inducing iNOS expression. Administration of aminoguanidine can significantly attenuate the injury, suggesting that iNOS expression may play a critical role in the lung injury induced in these 2 models.     

Extranodal Rosai-Dorfman disease with multilevel lumbar spinal lesions

The authors describe the case of a 44-year-old man with multilevel lumbar spinal Rosai-Dorfman disease (RDD), a rare clinical entity. To the authors' knowledge, there have been only 2 cases of lumbar spinal involvement of RDD (epidural) reported in the literature, and the current case is the third but the only one showing lumbar spinal intradural involvement of RDD. This case of RDD mimicked a meningioma both clinically and radiologically. The patient underwent a procedure in which the tumor was excised, and postoperatively the patient made a clinically acceptable recovery. Vertebral canal involvement of RDD should be considered in the differential diagnosis of vertebral canal tumors. Resection is an acceptable treatment option.     

Histological factors contributing to a high risk of recurrence of submucosal invasive cancer (pT1) of the colon and rectum after endoscopic therapy

We analyzed the histological high-risk factors for recurrence of submucosal invasive carcinomas (pT1) of the colon and rectum after endoscopic therapy, examining pT1 cancers treated primarily by endoscopic resection within a 23-year period. We compared recurrent and nonrecurrent cancers, evaluating the following "highrisk factors" of the primary lesion: massive invasion, a surgical margin <2 mm but negativity for cancer in the cut end, poorly differentiated adenocarcinoma (PD) (G3), undifferentiated carcinoma (G4), and/or positive angiolymphatic invasion. The following histological factors were defined as predictive of a low risk: minimum invasion, a surgical margin >2 mm, well or moderately differentiated adenocarcinoma (G1, G2), and no evidence of angiolymphatic invasion. We analyzed the records of 37 patients with pT1 cancers, including 15 with high-risk factors who underwent subsequent resection. Local recurrence with or without liver metastases developed in 4 of these 15 patients. The histological type was PD in three (75%) of the four recurrent lesions. All four (100%) lesions showed a desmoplastic response (DR). Only 1 (9%) of the 11 patients without recurrence after subsequent surgery had a lesion with a small component of PD, and only three (27%) lesions showed a mild DR. We concluded that endoscopic therapy is inadequate for pT1 cancers with a histological PD component, and/or a DR in the cancer stroma.     

Migration of endoclip into duodenum. A rare complication after laparoscopic cholecystectomy

The long-term effect of spilled clips within the abdominal cavity after laparoscopic cholecystectomy is unknown. However, most surgeons agree that the migration of clips has limited clinical consequences. A few cases have been reported of clips that have migrated into the common bile duct, causing stone formation and/or obstructions. We present a case of gallstone pancreatitis treated with laparoscopic cholecystectomy that was complicated by bile leakage from the cystic duct stump 1 day after the procedure. Although the leaking stump sealed itself spontaneously after the placement of a biliary stent, a clip had migrated directly to the superior wall of the first portion of the duodenum. Herein the details of the patient's history are presented. We also discuss the possible mechanisms of clip migration and describe some preventive measures.