Mesenteric neovascularization during spring-mediated intestinal lengthening

BackgroundShort gut syndrome, a condition characterized by inadequate absorption of nutrients owing to decreased bowel length, has minimal avenues for treatment. We have proposed spring-mediated distraction enterogenesis to lengthen bowel in porcine jejunum as a treatment for short gut. We aim to evaluate the extent of mesenteric neovascularization in segments of lengthened bowel via spring-mediated enterogenesis.MethodsFemale juvenile Yucatan pigs underwent laparotomy and insertion of gelatin-encapsulated compressed nitinol springs, held in place with plication sutures, into the jejunum. At surgery and sacrifice, macroscopic mesenteric blood vessels were counted between the plication sites. Histologic samples of the mesentery were obtained to evaluate microscopic vasculature.ResultsA statistically significant increase in macroscopic mesenteric blood vessels was seen after intestinal lengthening (before: 1.9 ± 0.7 vessels, after: 4.7 ± 1.2 vessels, p = 0.001). A statistical significance is also seen in the density of arterioles (control: 3.0 ± 3.0 vessels/mm, spring: 7.0 ± 9.0 vessels/mm, p = 0.01) and venules (control: 4.0 ± 3.0 vessels/mm, spring: 8.0 ± 8.0 vessels/mm, p = 0.003).ConclusionIntestinal segments lengthened by intraluminal springs demonstrated total greater number of macroscopic vessels and microscopic blood vessels per length of mesentery as compared to control. This suggests local changes within the mesentery to recruit blood supply to growing intestine.Level of evidenceN/AType of studyTreatment study.     

Mechanical lengthening of porcine small intestine with decreased forces

Introductionshort bowel syndrome is marked by inadequate intestinal surface area to absorb nutrients. Current treatments are focused on medical management and surgical reconfiguration of the dilated intestine. We propose the use of spring-mediated distraction enterogenesis as a novel intervention to increase intestinal length. Given our previous success lengthening intestinal segments using springs with spring constant ~7 N/m that exerts 0.46 N or higher, we sought to determine the minimal force needed to lengthen porcine small intestinal segments, and to explore effects on intestine over time.MethodsJuvenile Yucatan pigs underwent laparotomy with enterotomy to introduce nitinol springs intraluminally (n = 21 springs). Bowel segments (control, spring-distracted) were retrieved on post-operative day (POD) 7 and 14, and lengths measured. Thickness of cross-sectional intestinal layers were measured using H&E, and submucosal collagen fiber orientation measured using trichrome stained sections.Resultsall pigs survived to POD7 and 14. Spring constants of at least 2 N/m exerting a minimum force of 0.10 N significantly lengthened intestinal segments (p <0.0001). The stronger the spring force, the greater the induced thickness of various intestinal layers at POD7 and 14. Collagen fiber orientation was also more disordered because of stronger springs.Conclusiona spring constant of approximately 2 N/m exerting 0.10 N and greater significantly lengthens intestinal segments and stimulates intestinal structural changes at POD7 and 14. This suggests a decreased force is capable of inducing spring-mediated distraction enterogenesis.     

Huge filarial elephantiasis vulvae in a Nigerian woman with subfertility

Filariasis is a helminthic infection caused by tissue nematodes. It is estimated that at least 120 million people are infected worldwide and another 1 billion are “at risk” of infection. The prevalence is increasing due to uncontrolled urbanization in many of the endemic countries. The geographical distribution is determined mainly by climate and the distribution of the mosquito vector. We report a case of huge filarial elephantiasis of the vulva, in a 40-year-old multipara with background history of secondary infertility. She had excision of the elephantoid vulva lesion under general anaesthesia. A nontender irreducible pedunculated mass (25 cm × 21 cm) with a large stalk arising from the right groin down to the ipsilateral labia majora was removed. A similar mass on the left groin, measuring 10 cm × 6 cm was removed. Diagnosis was confirmed at histopathologic analysis of the excised masses. Patient was placed on diethyl carbamazine.     

Improving Health Professions Students’ Understanding of Interprofessional Roles Through Participation in a Patient Stabilization Simulation

Objective. To teach interprofessional communication and teamwork skills to health professions students through a standardized patient simulation on acute patient stabilization and measure the impact on learners’ perceptions of interprofessional collaboration.Methods. Medical and pharmacy students in their final year and post-licensure nurses in their initial six-month probationary period worked together to stabilize a simulated acutely ill standardized patient. Perceptions of IPE were assessed pre- and post-simulation using the Student Perceptions of Interprofessional Clinical Education-Revised Instrument, version 2 (SPICE-R2). Medical student participants’ scores were compared to those of a concurrently enrolled cohort of medical students who did not participate in the simulation.Results. Eighty learners participated in the simulation and all completed pre and post SPICE-R2 assessments. Learners’ perceptions increased significantly in all domains, including understanding of roles in collaborative practice, interprofessional teamwork and team-based practice, and patient outcomes from collaborative practice. Compared to the control cohort, participants’ perceptions of team-based practice and the impact on patient outcomes improved significantly, while a statistically similar improvement in scores for understanding of roles and responsibilities was seen. The SPICE-R2 scores increased similarly among students in each profession. Repeat exposure to the simulation continued to improve perceptions but not as robustly as the initial simulation.Conclusion. This simulation changed learners’ perceptions of how interprofessional collaboration affects patient care, which supports the incorporation of standardized patient-based interprofessional education even in the late-stage education of health professionals.     

Rehabilitative management offered Nigerian localized and generalized aggressive periodontitis patients

This paper highlights the typical clinical features of aggressive periodontitis (formerly known as juvenile periodontitis in the South Western region of Nigeria), the attending psychological effect following tooth loss, and the rehabilitative management offered which included periodontal therapy, psychotherapy, and prosthetic replacement of the missing teeth. The psychotherapy is the main distinguishing treatment in this study from previously reported modes of management of this disease entity. Subjects were from a part of the South Western region of Nigeria, and ages ranged from 15 to 22 years. They all presented very late with subsequent gross periodontal breakdown and subsequent psychological depression. The mean values of the probing depth (mm), degree of mobility, and the amount of bone fill (mm) from the periapical radiographs were recorded pre and post-operatively. The missing teeth were replaced with acrylic dentures, and psychotherapy was offered at three levels (individual, group, and conjoint-family psychotherapy). There was significant improvement of these clinical parameters six months after treatment, and the partial denture replacement of the missing teeth improved their appearance as expected but did not totally improve the initial depressive state. The psychotherapy offered gave the patients positive psychological effects that further restored their ability to socialize in their environment, which added to their positive experience of life. In conclusion the typical clinical features of localized aggressive periodontitis (LAP) and generalized aggressive periodontitis (GAP) patients in our environment are late presentation with gross periodontal tissue breakdown. Psychotherapy is an important aspect in the management of this group of patients in conjunction with the periodontal and prosthetic management, which gives total rehabilitation.     

Cutaneous manifestations of deep mycosis: an experience in a tropical pathology laboratory

Background:

Cutaneous manifestations of deep mycotic infection are fraught with delayed or misdiagnosis from mainly cutaneous neoplastic lesions.

Aim:

This study is designed to present our experience of these mycoses in a pathology laboratory in the tropics.

Materials and Methods:

A clinicopathologic analysis of deep mycotic infections was conducted over a 15 years period Formalin fixed and paraffin wax processed biopsies were stained with hematoxylin and eosin, periodic acid Schiff (PAS), and Grocott''s methenamine silver (GMS) for the identification of fungus specie. Patients’ bio-data and clinical information were obtained from records.

Results:

Twenty males and seven females presented with 6 months to 6 years histories of varying symptoms of slow growing facial swellings, nodules, subcutaneous frontal skull swelling, proptosis, nasal blockage, epistaxis, discharging leg sinuses, flank mass, convulsion and pain. Of the 27 patients, four gave antecedent history of trauma, two had recurrent lesions which necessitated maxilectomy, two presented with convulsion without motor dysfunction while one had associated erosion of the small bones of the foot. None of the patients had debilitating illnesses such as diabetes mellitus, tuberculosis, and HIV infection. Tissue histology revealed histoplasmosis (10), mycetoma (9), subcutaneous phycomycosis (6), and phaeohyphomycosis (2).

Conclusion:

Deep mycoses may present primarily as cutaneous lesions in immunocompetent persons and often elicit distinct histologic inflammatory response characterized by granuloma formation. Diagnosis in resource constraint setting can be achieved with tissue stained with PAS and GMS which identifies implicated fungus. Clinical recognition and adequate knowledge of the pathology of these mycoses may reduce attendant patient morbidity.     

Human mycetoma

BACKGROUND: Mycetoma is a tropical superficial fungal infection endemic in parts of Africa. It affects the foot and leg commonly, but any part of the body may be involved. Mycetoma presents with characteristic discharging sinuses containing fungal granules, a picture that is pathognomonic. However, the disease may present without these characteristic features, thus causing diagnostic difficulty with other chronic granulomatous infections such as tuberculosis or benign skin lesions. METHODS: A review of four male and three female patients aged 28-70 years with mycetoma seen during a six-year period. RESULTS: The duration of the lesion before presentation was between two and six years (median five years). Clinical presentation included pigmented cutaneous nodules, depigmented spots, multiple discharging sinuses, or a fungating mass with bone erosion, involving almost any part of the body (face, trunk, and leg). The range of clinical misdiagnoses included skin tuberculosis, fibroma, amelanotic melanoma, basal-cell carcinoma, and brain tumor. Histologic examination of tissue biopsies showed amorphous aggregates of eosinophilic granules in a background of chronic suppurative inflammation. CONCLUSION: Mycetoma is a disease with sporadic occurrence in our environment. The presentation and clinical course may be confused with those of many skin diseases. Knowledge of mycetoma pathology is important for prompt diagnosis and treatment of this indolent clinical entity.     

Laparoscopic versus ultrasound-guided visualization of transversus abdominis plane blocks

BackgroundUltrasound-guided (US) transversus abdominis plane (TAP) block is commonly utilized as part of a multi-modal approach for postoperative pain management. This study seeks to determine whether laparoscopic-guided TAP blocks are as effective as US-guided TAP blocks among pediatric patients.MethodIn this prospective, randomized controlled trial, pediatric patients undergoing laparoscopic procedures were randomly assigned to one of two treatment arms: US-guided TAP block (US-arm) or laparoscopic-guided TAP block (LAP-arm). Primary outcome was PACU pain scores. Secondary outcomes included PACU opioid consumption, block completion time and block accuracy.ResultsTwenty-five patients were enrolled in each arm. In the LAP-arm, 59% of blocks were in the transversus abdominis plane compared to 74% of TAP blocks in the US-arm (p = 0.18). Blocks were completed faster in the LAP-arm (2.1 ± 1.9 vs. 7.9 ± 3.4 min, p<0.001). The average highest PACU pain score was 3.4 ± 3.1 for the LAP-arm and 4.3 ± 3.8 for the US-arm (p = 0.37). Overall PACU pain scores and opioid consumption were similar between the groups (1.2 ± 1.3 vs. 1.6 ± 1.6, p = 0.24; 2.2 ± 5.8 vs. 0.9 ± 1.4MME, p = 0.26).ConclusionLaparoscopic TAP blocks have equivalent efficacy in post-operative pain scores, narcotic use, and tissue plane accuracy as compared to US-guided TAP blocks. They are also completed faster and may result in less operating room and general anesthetic time for the pediatric patient.