How to isolate a high output enteroatmospheric fistula in the open abdomen with negative pressure therapy: an institution's step by step guide to the VAC donut.

There is multiple evidence to suggest that isolation techniques of high output enteroatmospheric fistulas (EAF) in open abdomens can be advantageous in controlling fistula effluent while allowing time for abdominal wall to granulate. The large loss of proteins, electrolytes and fluid, and the distressing nature of the open abdomen for both patients and doctors, make managing these EAFs a clinical challenge. We present our experience with a high output mucosal protruding EAF and the creation of a 'VAC donut' allowing a successful diversion of the enteric content whilst promoting granulation of the tissue bed.

Impact of single-stage laparoscopic trans-cystic exploration on hospital procedures, admissions and length-of-stay in common bile duct stone clearance.

BACKGROUND: Single-stage approach with bile duct exploration is considered the most efficient and cost-effective method of bile duct clearance. In Australia, apart from centres with subspecialty interests, notably in Brisbane, Queensland, a multi-stage approach with endoscopic retrograde cholangiopancreatography (ERCP) is used more frequently. We aim to evaluate the impact of single stage laparoscopic trans-cystic exploration (LTCE) versus multi-stage approach for choledocholithiasis. METHODS: This was a retrospective cohort study. Medicare Benefits Schedule codings were used to identify patients who had the following procedures between December 2011 and December 2019: laparoscopic cholecystectomy (LC) and ERCP, LC and LTCE, LC and LTCE and ERCP. Primary outcomes were number of hospital procedures, admissions and additive length of stay (aLOS), the cumulative hospital stay from admission to discharge. RESULTS: Of 607 patients, 204 (34%) patients received a single-stage LTCE, while 403 (66%) patients had a multi-stage approach. In the LTCE group, 82% (168) patients and 93% (190) patients had one procedure and one admission respectively for stone clearance (P = 0.001). The median aLOS was 4 days for LTCE versus 7 days for multi-stage approach (P = 0.001; 95% CI for difference - 3 to -2). In the multi-stage group, 16% (65) patients had three or more procedures and 49% (199) patients required two or more hospital admissions to achieve stone clearance. CONCLUSION: LTCE for stone clearance can be successfully accomplished with reductions in hospital admissions, number of procedures and length of stay. This has further economic and health resource implications.

Investigation of Heterochromatin Protein 1 Function in the Malaria Parasite Plasmodium falciparum Using a Conditional Domain Deletion and Swapping Approach.

The human malaria parasite Plasmodium falciparum encodes a single ortholog of heterochromatin protein 1 (PfHP1) that plays a crucial role in the epigenetic regulation of various survival-related processes. PfHP1 is essential for parasite proliferation and the heritable silencing of genes linked to antigenic variation, host cell invasion, and sexual conversion. Here, we employed CRISPR/Cas9-mediated genome editing combined with the DiCre/loxP system to investigate how the PfHP1 chromodomain (CD), hinge domain, and chromoshadow domain (CSD) contribute to overall PfHP1 function. We show that the 76 C-terminal residues are responsible for targeting PfHP1 to the nucleus. Furthermore, we reveal that each of the three functional domains of PfHP1 are required for heterochromatin formation, gene silencing, and mitotic parasite proliferation. Finally, we discovered that the hinge domain and CSD of HP1 are functionally conserved between P. falciparum and P. berghei, a related malaria parasite infecting rodents. In summary, our study provides new insights into PfHP1 function and offers a tool for further studies on epigenetic regulation and life cycle decision in malaria parasites.IMPORTANCE Malaria is caused by unicellular Plasmodium species parasites that repeatedly invade and replicate inside red blood cells. Some blood-stage parasites exit the cell cycle and differentiate into gametocytes that are essential for malaria transmission via the mosquito vector. Epigenetic control mechanisms allow the parasites to alter the expression of surface antigens and to balance the switch between parasite multiplication and gametocyte production. These processes are crucial to establish chronic infection and optimize parasite transmission. Here, we performed a mutational analysis of heterochromatin protein 1 (HP1) in P. falciparum We demonstrate that all three domains of this protein are indispensable for the proper function of HP1 in parasite multiplication, heterochromatin formation, and gene silencing. Moreover, expression of chimeric proteins revealed the functional conservation of HP1 proteins between different Plasmodium species. These results provide new insight into the function and evolution of HP1 as an essential epigenetic regulator of parasite survival.

Angioleiomyoma presenting as a lateral neck lump: a diagnostic dilemma.

Angioleiomyomas are defined as benign dermal or subcutaneous tumours consisting of smooth muscle cells arranged around vascular channels. Head and neck angioleiomyomas are rarely encountered as they usually occur in the extremities. We report a case of a 71-year-old male, who presented with a 3-month history of a painless lateral neck lump. Ultrasound and computed tomography scans localised the suspicious hypervascular tumour to the right supraclavicular fossa between the two heads of sternocleidomastoid muscle. He subsequently underwent an excisional biopsy, where histological analysis determined that the lateral neck mass was a venous subtype angioleiomyoma. To the best of our knowledge, this is only the third reported case of an angioleiomyoma in the supraclavicular fossa. Although supraclavicular masses are typically synonymous with malignancy, this case report highlights that angioleiomyoma should be considered as a differential diagnosis when investigating patients with a lateral neck lump.

Mapping and functional analysis of heterochromatin protein 1 phosphorylation in the malaria parasite Plasmodium falciparum.

Previous studies in model eukaryotes have demonstrated that phosphorylation of heterochromatin protein 1 (HP1) is important for dynamically regulating its various functions. However, in the malaria parasite Plasmodium falciparum both the function of HP1 phosphorylation and the identity of the protein kinases targeting HP1 are still elusive. In order to functionally analyze phosphorylation of P. falciparum HP1 (PfHP1), we first mapped PfHP1 phosphorylation sites by liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis of native PfHP1, which identified motifs from which potential kinases could be predicted; in particular, several phosphorylated residues were embedded in motifs rich in acidic residues, reminiscent of targets for P. falciparum casein kinase 2 (PfCK2). Secondly, we tested recombinant PfCK2 and a number of additional protein kinases for their ability to phosphorylate PfHP1 in in vitro kinase assays. These experiments validated our prediction that PfHP1 acts as a substrate for PfCK2. Furthermore, LC-MS/MS analysis showed that PfCK2 phosphorylates three clustered serine residues in an acidic motif within the central hinge region of PfHP1. To study the role of PfHP1 phosphorylation in live parasites we used CRISPR/Cas9-mediated genome editing to generate a number of conditional PfHP1 phosphomutants based on the DiCre/LoxP system. Our studies revealed that neither PfCK2-dependent phosphorylation of PfHP1, nor phosphorylation of the hinge domain in general, affect PfHP1's ability to localize to heterochromatin, and that PfHP1 phosphorylation in this region is dispensable for the proliferation of P. falciparum blood stage parasites.

Continuous Suction Isoperistaltic Gastroesophagostomy for Esophageal Perforation.

Esophageal perforation is a surgical emergency with significant morbidity. Management of this condition is complex and constantly evolving. To our knowledge, this is the first case series describing repair of esophageal perforation with the use of an isoperistaltic gastroesophagostomy tube connected to continuous suction. We present three patients successfully managed using this technique.

Paracaecal hernia: a case report on the evolving role of laparoscopy.

A paracaecal hernia, a type of pericaecal hernias, is a rare cause of small intestinal obstruction. Failure of early recognition and reduction of this type of internal hernia may lead to strangulation of the herniated intestine. There has been a number of case reports in the literature about the different types of pericaecal hernias, however the anatomy of these hernias is still poorly understood and the management is still evolving. We are presenting a 75year old woman, who presented clinically and radiologically with distal small intestinal obstruction. Her past medical history was unremarkable and she had no prior abdominal surgery. After resuscitation, she was taken to the operating theatre for a diagnostic laparoscope, which showed a herniated loop of ileum through a congenital defect in the parietocaecal fold. Reduction of that loop and closure of the peritoneal defect were achieved laparoscopically. Following the procedure, the patient recovered very quickly and she was discharged home within 48h of her initial admission. Patients with pericaecal hernias tend to present with symptoms of distal small intestinal obstruction. The presence of localised peritonism in the right iliac fossa usually indicate strangulation and that should prompt an urgent surgical intervention. In summary, based on our case, excellent results were achieved from early laparoscopic intervention. Therefore, we recommend early laparoscopy for patients presenting with small intestinal obstruction with no history of abdominal surgery.

Massive pericardial effusion following a laparoscopic adjustable gastric banding.

Laparoscopic adjustable gastric banding (LAGB) is currently the most common bariatric surgical procedure. The most frequent complications of LAGB surgery are pouch dilatation, gastric prolapse, band erosion, stoma obstruction and access-port problems. We report a rare life-threatening case of massive pericardial effusion as a complication of an infected Lap-Band. The management of this condition included subxiphoid pericardial window, removal of the band and later conversion to gastric bypass.

An easy method of deflating a blocked Foley balloon.

Blocked Foley balloons are occasionally encountered by many urological surgeons. A number of methods of removing a blocked balloon catheter have been advocated. They are usually invasive, time and resource consuming and often ineffective. A non-invasive, reliable and safe technique of deflating a blocked catheter balloon by inserting a Glidewire through the balloon channel is reported in the present paper.