Closure of the abdominal wall with acellular dermal allograft in intestinal transplantation.

Loss of abdominal domain is a common problem in intestinal transplantation. Several surgical options are available perioperatively for abdominal wall reconstruction. This study reports the management and complications for intestinal transplant patients with abdominal wall closure either primarily or with foreign material. This single center study reviews the records of intestinal transplant patients between 2004 and 2010. Study outcomes included reoperation for dehiscence, hernia or enterocutaneous fistula. There were 37 of 146 patients (25%) who required implantation of foreign material at transplant. Of these 37, 30 (81%) had implantation of acellular dermal allograft (ADA) and 7 (19%) implantation of another mesh. Perioperative dehiscence was rare with 2/109 (2%) for primary closure, 0/30 (0%) for ADA and 1/7 (14%) for other mesh. There were 12/146 (8%) patients who underwent ventral hernia repair: primary closure 7/109 (6%), ADA 3/30 (10%) and other mesh 2/7 (28%). There were 4/146 (3%) patients who required surgery for enterocutaneous fistulas: 2/109 (2%) primary closure, 1/30 (3%) ADA and 1/7 (14%) synthetic mesh. Abdominal wall reconstruction with ADA biologic mesh provides an expeditious means of performing a tension-free closure of the fascial layer after intestinal transplantation with complications similar to those seen for primary closure.

Improved intra-operative reduction control using a three-dimensional mobile image intensifier - a proximal tibia cadaver study.

This study aimed to analyse whether the precision of a three-dimensional mobile image intensifier (ISO-C 3D) differs from conventional two-dimensional fluoroscopy and high resolution CT scan in a fracture model of the proximal tibia. A depression fracture of the medial plateau (AO/OTA 41-B2.3) was created in 12 formalin-fixed, human cadaver knees. The cartilage of the depression could be positioned above (+1mm, +2mm), below (-1mm, -2mm), or in line with the joint surface. Fluoroscopy, computed tomography (CT) scans, and ISO-C 3D scans (four different protocols: 100 images, 66 images, 50 images, and 33 images) were done for each fracture level. Three independent observers assessed each imaging set. The difference between the estimated reduction and the real reduction was used for statistical analysis. Our hypothesis was that no differences in the precision exist between the imaging techniques (p<0.05). The conventional image intensifier group (0.7 mm+/-0.67) showed significantly higher deviations than the CT group (0.3 mm+/-0.43; p<0.001) and significantly higher deviations than all ISO-C 3D groups (0.4-0.5 mm; p<0.001). Of the ISO-C 3D groups, only the scan protocol with the lowest number of images (0.5 mm+/-0.51) showed significantly lower precision than the CT group (p<0.001). It was concluded that the three-dimensional mobile image intensifier showed higher precision in reduction assessment in a fracture model of the tibial plateau compared to fluoroscopy. High resolution CT scans should remain the standard for post-operative assessment of reduction outside the operating theatre.

Apolipoprotein B-100: employing the electrochemiluminescence technology of the Elecsys systems for the detection of the point mutation Arg(3500)Gln.

Apolipoprotein B-100 (apo B-100) plays an essential role in lipoprotein metabolism where it is involved in the clearance of LDL particles from the bloodstream. The mutation Arg3500Gln in the apo B-100 gene impairs the binding of the LDL particles to the LDL receptor, resulting in elevated LDL-cholesterol levels in the blood which, in turn, fuel the development of premature atherosclerosis. Here we describe a rapid, automated test for the detection of the most frequent mutation in the apo B-100 gene. This PCR-based test employs electrochemiluminescence as detection technology and allows the reliable discrimination of all genotypes. The assay has been especially developed for the non-specialized routine clinical chemistry laboratory by employing an analyzer and chemistry often present in this type of labof1tory. Because of its low costs and easy handling the assay can be performed on a daily basis.

Apolipoprotein E polymorphism: automated determination of apolipoprotein E2, E3, and E4 isoforms.

Apolipoprotein E (apo E) plays an essential role in lipoprotein metabolism, where it is involved in the clearance of chylomicrons and very low density lipoproteins. Apart from some rare variants, apo E exists in three common isoforms (E2, E3, and E4). The different isoforms have not only been associated with different plasma lipid levels but have also been correlated with certain pathological conditions, such as lipid disorders (dysbetalipoproteinemia, hypercholesterolemia), cardiovascular diseases, and Alzheimer's disease. Here we describe a rapid, automated test for the determination of the most frequent polymorphisms (E2, E3, and E4). This polymerase chain reaction-based test allows the reliable discrimination of all six genotypes. The assay has been developed especially for the nonspecialized routine clinical laboratory by employing an analyzer and chemistry often present in this type of laboratory. Because of its low costs and easy handling, the assay can be performed on a daily basis.

A 6-Mb high-resolution physical and transcription map encompassing the hereditary prostate cancer 1 (HPC1) region.

Several hereditary disease loci have been genetically mapped to the chromosome 1q24-q31 interval, including the hereditary prostate cancer 1 (HPC1) locus. Here, we report the construction of a 20-Mb yeast artificial chromosome contig and a high-resolution 6-Mb sequence-ready bacterial artificial chromosome (BAC)/P1-derived artificial chromosome (PAC) contig of 1q25 by sequence and computational analysis, STS content mapping, and chromosome walking. One hundred thirty-six new STSs, including 10 novel simple sequence repeat polymorphisms that are being used for genetic refinement of multiple disease loci, have been generated from this contig and are shown to map to the 1q25 interval. The integrity of the 6-Mb BAC/PAC contig has been confirmed by restriction fingerprinting, and this contig is being used as a template for human chromosome 1 genome sequencing. A transcription mapping effort has resulted in the precise localization of 18 known genes and 31 ESTs by database searching, exon trapping, direct cDNA hybridization, and sample sequencing of BACs from the 1q25 contig. An additional 11 known genes and ESTs have been placed within the larger 1q24-q31 interval. These transcription units represent candidate genes for multiple hereditary diseases, including HPC1.

[Inpatient rehabilitation in inpatients with chronic obstructive lung diseases (COPD): effect on physical capacity for work, psychological wellbeing and quality of life]. / Stationäre Rehabilitation bei Patienten mit chronisch obstruktiver Lungenkrankheit (COLK): Effekte auf körperliche Leistungsfähigkeit, psychisches Wohlbefinden und Lebensqualität.

Success of inpatient rehabilitation for patients with chronic obstructive pulmonary disease (COPD) was assessed in a prospective study of 39 patients (mean age = 71 years). Six months after hospital stay (mean duration 22.4 days), physical endurance as assessed by the 6-minute walk distance remained unchanged. Subjective health measures improved (SF36 21 vs 29%; p < 0.05), MRC-dyspnoea was reduced (2.61 vs 2.19; p < 0.05) and measures of global quality of life also improved (56.1 vs 67.5; p < 0.05). Meanwhile, anxiety symptoms were reduced (7.7 vs 6.0; p < 0.05); no changes in depression scores were observed (6.8 vs 6.2; p = 0.271). A novel visual method to assess the burden of suffering, PRISM (Pictorial Representation of Illness and Self Measure), was applied for the first time in COPD patients. PRISM scores improved significantly (6.3 vs 12.2; p < 0.001). In conclusion, inpatient pulmonary rehabilitation improved subjective physical health measures and reduced anxiety levels.

Haemochromatosis: automated detection of the two point mutations in the HFE gene: Cys282Tyr and His63Asp.

Hereditary haemochromatosis (HH) is one of the most common inherited diseases among Caucasians. Two mutations in the HFE gene have been implicated in HH: 80 to 90% of the patients with HH are homozygous for the point mutation CYS282Tyr, while the majority of the remaining patients displays either a compound heterozygosity for the mutation CYS282Tyr and the point mutation HIS63Asp, or are homozygous for HIS63Asp. Though the disease can be treated easily, symptoms are non-specific, and onset and severity are influenced by environmental factors, and therefore the disease can remain undetected until decades of iron overload lead to irreversible damage in a variety of organs, which may result in their failure. In order to detect patients with HH, simple and cost-effective tests are needed. We have developed a rapid, automated, PCR-based test which makes use of a diagnostic restriction site in each of two amplified fragments. The test employs off-the-shelf chemistry and uses the automated detection process of an immunoassay analyzer that is available in many clinical laboratories, thus avoiding an additional investment in a more specialized PCR analyzer. Because of its low costs and easy handling, the assay is particularly suited for the routine clinical laboratories.

Activated protein C resistance: automated detection of the factor V Leiden mutation by mismatch hybridization.

BACKGROUND: A single point mutation in the factor V gene has been demonstrated to be the cause of factor Va resistance to proteolytic cleavage by activated protein C. Knowledge of the patient's genetic disposition is of great importance in situations such as pregnancy, surgery, use of oral contraceptives, and immobilization. METHODS: We have developed a rapid, automated test for the detection of the factor V mutation that makes use of differences in thermal stability between perfect-match and non-perfect-match hybrids. A DNA fragment spanning the mutation is amplified with a biotin-labeled primer. Ruthenium-labeled oligonucleotides, perfectly matching either the biotinylated wild-type strand or the biotinylated mutation strand, are added. Heating to 95 degrees C and subsequent cooling lead to the formation of double-stranded DNA. Under the conditions chosen, ruthenium-labeled oligonucleotides form stable, double-stranded DNA with the biotinylated strand only if both strands perfectly match each other. The ruthenium signal is measured on a modified Elecsys 1010 system (Roche Diagnostics). RESULTS: The ratio between the signals obtained with perfectly matching and non-perfectly matching oligonucleotides reflects the genetic status. Analyzed samples can be divided into three nonoverlapping groups based on these ratios. We confirmed the reliability of the method by analyzing several samples of known genetic status; the results were identical in every single instance. CONCLUSIONS: The test discriminates unambiguously between the heterozygous and the homozygous states. Because of its low costs and easy handling, the assay is suitable for use in routine laboratories of clinical chemistry.

Activated protein C (APC)-resistance: automated detection of the point mutation at position 1691 in the factor V gene.

Proteolytic cleavage of factor Va, caused by activated protein C, is an important mechanism in limiting clot formation in normal haemostasis. A single point mutation in the factor V gene has been demonstrated to cause resistance of factor Va to proteolytic cleavage by activated protein C. With an 8-fold increased risk of thrombosis and a 2 to 13% prevalence in the Caucasian population for the heterozygous state of this mutation, knowledge of the patient's genetic disposition is of great importance in conditions such as pregnancy, surgery, use of oral contraceptives and immobilization. Therefore we have developed an automated test for the detection of the factor V mutation. This PCR based test makes use of the disappearance of an Mnl 1 restriction site if the mutation is present. The assay has been developed for the widely used ES-systems of Boehringer Mannheim. The test discriminates between the heterozygous and the homozygous state. Because of its low costs and easy handling the assay can be used as a screening test and can be performed in routine clinical laboratories.

Downregulation of c-kit (stem cell factor receptor) in transformed hematopoietic precursor cells by stroma cells.

We show a dramatic downregulation of the stem cell factor (SCF) receptor in different hematopoietic cell lines by murine stroma. Growth of the human erythroid/macrophage progenitor cell line TF-1 is dependent on granulocyte-macrophage colony-stimulating factor (GM-CSF) or interleukin-3 (IL-3). However, TF-1 cells clone and proliferate equally well on stroma. Independent stroma-dependent TF-1 clones (TF-1S) were generated on MS-5 stroma. Growth of TF-1S and TF-1 cells on stroma still requires interaction between c-kit (SCF receptor) and its ligand SCF, because antibodies against c-kit inhibit growth to less than 2%. Surprisingly, c-kit receptor expression (RNA and protein) was downregulated by 2 to 3 orders of magnitude in TF-1S and TF-1 cells grown on stroma. This stroma-dependent regulation of the kit receptor in TF-1 was also observed on exposure to kit ligand-negative stroma, thus indicating the need for heterologous receptor ligand interaction. Removal of stroma induced upregulation by 2 to 4 orders of magnitude. Downregulation and upregulation of c-kit expression could also be shown for the megakaryocytic progenitor cell line M-07e and was comparable to that of TF-1, indicating that stroma-dependent regulation of c-kit is a general mechanism. Downregulation may be an economic way to compensate for the increased sensitivity of the c-kit/ligand interaction on stroma. The stroma-dependent c-kit regulation most likely occurs at the transcriptional level, because mechanisms, such as splicing, attenuation, differential promoter usage, or mRNA stability, could be excluded.

Valvular endocarditis due to Mycobacterium tuberculosis.

Granulomas due to Mycobacterium tuberculosis are rarely observed in valvular structures. When observed, they are associated with disseminated tuberculosis in immunocompromised patients. We report the first case of tuberculous valvular endocarditis isolated in an immunocompetent patient. The patient had severe mitral valve regurgitation due to a perforation of the anterior leaflet of the mitral valve. M. tuberculosis was cultured from the vegetations and no other tuberculous foci were identified. This case exemplifies the protean manifestations of M. tuberculosis infections.

Effects of mycobacteria on regulation of apoptosis in mononuclear phagocytes.

Since apoptosis is observed in tuberculous granulomata, we investigated the molecular mechanisms underlying the apoptotic pathway in an in vitro model of mycobacterial infection of mononuclear phagocytes. We postulated that Mycobacterium tuberculosis could trigger the apoptotic pathway in macrophages, resulting in death of the microorganism by modulating the expression of bcl-2, bax, bcl-xL, and bcl-xS. We found that the mRNA of bcl-2, an inhibitor of apoptosis, was downregulated in peripheral blood monocytes (PBM) between 2 and 6 h following infection with M. bovis BCG or induction with heat-killed M. tuberculosis H37Ra. Western analysis showed a downregulation of the Bcl-2 protein, with a half-life of 24 h. At the same time points, there was no change in the expression of Bax or Bcl-xS, inducers of apoptosis, but Bcl-xL, another inhibitor of apoptosis, was minimally upregulated by BCG. To determine if apoptosis could be a mechanism for growth inhibition in vivo, we obtained alveolar macrophages by bronchoalveolar lavage from involved sites in patients with active pulmonary tuberculosis. Using the TUNEL (terminal deoxynucleotidyltransferase mediated nick end labeling) technique, we observed significantly more apoptosis in involved segments of five tuberculosis patients (14.8 +/- 1.9%) than in those of normal controls (<1%, P = 0.02) or in uninvolved segments (4.3 +/- 0.9%, P < 0.05). We conclude that apoptosis of mononuclear phagocytes induced by M. tuberculosis occurs in vivo and that in an in vitro model of mycobacterial infection, apoptosis may be mediated by downregulation of Bcl-2.

[How safe is laparoscopic colon surgery?]. / Wie sicher ist die laparoskopische Kolonchirurgie?

Like any new technique, laparoscopic colon surgery must display results of the same or even better quality than established methods. In this hospital every laparoscopic colon operation has been registered since 1993. Patients were informed orally or in writing that the laparoscopic procedure is a new surgical technique and that, in particular, long term results in colon carcinoma are lacking. Patients who did not undergo the laparoscopic method were those who did not agree to this type of surgery, had tumor infiltrations without extensive liver metastases, or tumor sizes where laparotomy to retrieve the specimen is not much smaller than the open surgery incision. All operations without exception were performed by two laparoscopically skilled abdominal surgeons. We used four 12 mm Troicarts placed in a diamond position, the criteria for mobilization and resection strictly following those of open surgery. In rectosigmoid resection the specimens were extracted suprapubically, with simultaneous implantation of the anvil, in the other cases at appropriate sites. The anastomoses were created either by the double stapling technique or with a single layer running suture. 88 patients underwent operation. The change to open surgery was 11%. The reasons for the change were chiefly inflamed, bleeding diverticulitis tumor, carcinoma infiltrations and, in one case, bleeding. The anastomosis failure rate of the descendorectostomy, and in all laparoscopic colon operations, was 4% and compares favourably with the literature. This was also true of stenosis incidence. The wound infection rate is on the whole the same as for open surgery. The complication in the descendorectostomy is reduced by half in the laparoscopic procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Lineage-restricted recruitment of immature hematopoietic progenitor cells in response to Epo after normal hematopoietic cell transfection with EpoR.

The receptor for erythropoietin (EpoR) is normally restricted in its expression to the relatively mature cells of the erythroid and megakaryocytic lineages. Using retrovirus-mediated gene transfer, the wild-type EpoR and a constitutively activated mutant of the EpoR, EpoRR129C, were expressed in primary hematopoietic cells. Retroviral infection of day-12 murine fetal liver, followed by stimulation with Epo as a single stimulus, generated day-8 erythroid colonies resembling colonies derived from burst-forming units-erythroid (BFU-E). Similarly, murine post-5 fluorouracil (5-FU) bone marrow cells or fetal liver cells, induced to express EpoR and stimulated by Epo, displayed a significant enhancement of megakaryocyte colony formation, particularly of the BFU-megakaryocyte (BFU-Mk) colony type. Cultures of bone marrow cells transduced with the EpoR retrovirus and stimulated by Epo contained macrophage colonies but very few granulocyte colonies. Experiments to culture single clones demonstrated direct action of Epo on megakaryocyte and macrophage clones but failed to demonstrate a direct action on granulocyte precursors. A similar pattern of lineage-restricted effects was demonstrated in unstimulated cultures of cells infected with the EpoRR129C retrovirus. In summary, we have demonstrated Epo-induced recruitment of immature erythroid and megakaryocyte precursors induced to express the EpoR. Furthermore, we have also demonstrated lineage-restricted cell proliferation in response to Epo by normal myeloid hematopoietic cells transduced with the EpoR.

Relation of body fat distribution to reproductive factors in pre- and postmenopausal women.

The cross-sectional relations of several reproductive characteristics with self-reported waist-to-hip circumference ratio were evaluated in 44,487 pre- and postmenopausal women 40 to 65 years of age who were free of cancer, cardiovascular disease, and diabetes. All results were adjusted for age, body mass index, cigarette smoking, physical activity, and alcohol intake. Current use of postmenopausal hormones was associated with a significantly lower waist-to-hip ratio than either past or never use independent of type of menopause (0.778 versus 0.784, p = 0.0001 and 0.787, p = 0.0001, respectively), although associations with type (unopposed estrogens versus combined estrogen and progesterone) and duration of hormone therapy were not noted. Waist-to-hip ratio did not differ between pre- and postmenopausal women, but demonstrated weak positive associations with age at menarche, parity, and age at first birth, and a weak inverse association with past duration of breast-feeding. These data confirm relations of several reproductive factors and use of hormone replacement therapy with body fat distribution. Epidemiologic studies relating body fat distribution to disease outcomes in women should consider these factors as potential confounders.

Distinct classes of factor-independent mutants can be isolated after retroviral mutagenesis of a human myeloid stem cell line.

Retroviral insertion mutagenesis has been used extensively in vivo but not in vitro to induce and identify critical mutations during oncogenic progression and differentiation. We have developed a tissue culture system using the human, growth factor-dependent, hematopoietic precursor cell line TF-1 that permits the use of retroviral vectors to induce a large (up to 28-fold) increase in the mutation frequency to growth factor independence and thus the isolation of many mutants. The mutation frequency, as expected, is directly proportional to the number of retroviral insertions (2.2 x 10(-7) mutants per insertion). The mutant phenotypes can be subdivided into mutants that release growth factors and those that do not ("autonomous" mutants). The majority of growth factor-producing mutants release an unidentified ligand. A subset of the autonomous mutants shows alterations in expression of the alpha subunit of either the GM-CSF or the IL-3 receptor. One mutant expresses neither GM-CSF nor IL-3 alpha receptor chains, thus showing coordinate regulation of the alpha receptor subunits.

Upregulation of lineage specific receptors and ligands in multipotential progenitor cells is part of an endogenous program of differentiation.

Multipotent hematopoietic progenitor cell lines (FDCP-Mix) infected with a retroviral vector expressing the GM-CSF gene show functional downregulation of the GM-CSF receptor when maintained in IL-3 and activation of the receptor resulting in synchronous differentiation into mature granulocytes and macrophages on withdrawal of IL-3. This system has now been used to investigate whether or not receptors for some of the other growth factors are also influenced as a consequence of differentiation. We show here the lineage specific receptors for M-CSF, G-CSF and erythropoietin are all upregulated, regardless of whether or not differentiation is induced by GM-CSF or by other conditions. Concomitant induction of the mRNA coding for the ligands M-CSF and G-CSF, but not for erythropoietin, suggests that M-CSF and possibly G-CSF facilitate macrophage or granulocyte differentiation by an autocrine stimulation of the lineage specific receptors. FDCP-Mix mutants that are blocked in their ability to differentiate on exposure to GM-CSF, but that still require GM-CSF for proliferation, do not express increased levels of M-CSF receptor nor M-CSF. Based on these data, we suggest that expression of these lineage specific receptors is part of the intrinsic endogenous program of myeloid differentiation.

[Callus distraction by an internal bone transport system in unilateral fixation]. / Kallusdistraktion durch ein internes Knochentransportsystem bei unilateraler Fixation.

The problem of the treatment of bone defects can be solved by distraction osteogenesis as developed by ILIZAROV. This study shows how the bone transport technique can be adapted to every common external fixator while using a new internal distraction system. In 20 dogs a bone defect of 6 cm was performed at the femur. The femur was stabilized with an unilateral frame. A proximal or distal corticostomized bone fragment (length 2.5 cm) was descended through the bone defect (1 mm day). In 15 dogs a new regeneration of bone was observed. The quality of the regenerated bone depends upon stability of the fixation. In 5 dogs with osteotomy and rapid dislocation of the transported fragment no bone bridging was found.

[Indications and results of interlocking nailing of the femur]. / Indikationen und Resultate der Verriegelungsnagelung am Femur.

Since the introduction of an interlocking nail in 1972, different systems have been developed for the management of unstable femoral fractures. At the Clinic for Traumatology at the University Hospital of Zürich, the system of Grosse and Kempf was utilized until 1986, after which the AO universal nail system has been and still is used. Between 1981 and 1987, 63 femoral fractures in 62 patients have been treated with interlocking nails. The fractures were produced by a variety of mechanisms of injury, of which 75% were caused by traffic accidents. Associated injuries to other organ systems were sustained by 73% of the patients, overall there were 33% considered to have multiple trauma. 25% of the fractures were open. 44% (n = 28) required stable fixation, 15 were dynamized. The remaining 35 fractures were treated with dynamic nailings, 8 proximal and 27 distal. 15% were open nailings. Following dynamic stabilization full weight bearing was obtained after 56 and stable fixation after 120 days. A bridging callus was observed after an average of 8 weeks, and cortical bridging at 26 weeks following nailing. Complications included displacement of transversal screws in 3, local infections around the distal or proximal transversal screws in 3 and osteomyelitis at the fracture site in 3 cases.