Colorectal natural orifice transluminal endoscopic surgery (NOTES) and transvaginal/transrectal specimen extraction.

Advancements in minimally invasive surgery have both revolutionized laparoscopy and set the stage for the advancement of endoscopic surgery to the forefront of modern medicine. Natural orifice transluminal endoscopic surgery (NOTES) has now become a subject of great interest to surgeons worldwide who wish to reduce the morbidity associated with abdominal operations. However, the application of NOTES to colorectal surgery has thus far been limited due to the complex dissection, anastomosis and specimen extraction typically required when operating on the large bowel. For this reason, laparoscopic-assisted natural orifice surgery has been the means by which most surgeons have begun to incorporate natural orifice surgery into their established practices. Transanal endoscopic surgery, transvaginal-assisted laparoscopy and transrectal specimen extraction are all emerging techniques that may be currently employed, in a hybrid manner, with traditionally accepted laparoscopic operations in order to transition toward less invasive surgery and even pure NOTES. To this end, the vagina appears to be the most practical and widely used site of specimen extraction and adjunct access site for laparoscopic hybrid operations. An accompanying video demonstrates the authors' preferred technique for transvaginal and transrectal specimen extraction.

A safety analysis of oral prednisone as a pretreatment for rituximab in rheumatoid arthritis.

The administration of 100 mg of methylprednisolone intravenously (IV) 1/2 h prior to rituximab decreases the incidence of acute infusion reactions (AIRs). However, this pretreatment adds considerable time and conveys potential risk. We performed an open-label prospective assessment of oral prednisone as a pretreatment to rituximab. This was a 26-week open-label trial of 40 mg of oral prednisone given 1/2 h prior to rituximab as a prophylaxis against AIRs in patients with rheumatoid arthritis (RA). The primary endpoint was AIRs in the first 24 h after their initial infusion. Secondary endpoints include AIRs during the 24 h following their second infusion and any adverse events experienced during the 26-week study; efficacy measures were also followed as secondary endpoints. Sixty-four subjects were screened, and 50 subjects qualified. Fourteen out of the 50 (28 %) subjects had AIRs within 24 h of their first infusion. There were four AIRs (8.3 %) within 24 h of their second infusion. One of day 0 AIRs required drug discontinuation (wheezing/bronchospasm). Forty out of 50 (80 %) subjects experienced an adverse event during the 26 weeks. There were three SAEs deemed not to be study-drug related. The DAS28 and HAQ-DI all improved significantly at weeks 8, 16, and 26 compared to baseline. Historical controls demonstrate that 27 % of RA subjects experience AIRs with their first rituximab infusion. Our data suggest a smaller dose of oral prednisone is an effective alternative to IV methylprednisolone as a pretreatment for rituximab in patients with RA.

Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma.

OBJECTIVE: To report a retrospective chart review of patients who developed recto-urethral fistula (RUF) or several bladder neck contracture (BNC) recurrences after brachytherapy for treating localized prostate cancer. PATIENTS AND METHODS: In the past 3 years 18 patients with devastating complications after prostate brachytherapy were referred to our centre (RUF in 11, BNC in seven; mean age 63 years, range 60-81). All patients with RUF initially underwent diverting colostomy (six cystoprostatectomy with closure of the fistula, omental interposition and urinary diversion; one prostatectomy, bladder neck closure, fistula closure with omentum flap and continent vesicostomy). Three patients had the fistula closed with gracilis muscle flap using the York-Mason approach (one had a bladder neck closure and suprapubic tube; one elected to have no treatment). All patients with BNC had received three or more procedures to resect or incise their contracture. Four had diversion with a catheterizable segment, two used an indwelling Foley catheter and one uses intermittent catheterization. RESULTS: All six patients who had cystoprostatectomy with urinary diversion have had no recurrence of their RUF. All three treated with the York-Mason procedure healed well. One developed recurrent prostate adenocarcinoma and two a secondary neoplasia in the prostate or rectum (leiomyosarcoma and neuroendocrine, respectively). The enterocystoplasty patient developed sepsis after colostomy reversal and subsequently died. In those patients with BNC, the four who underwent urinary diversion fared well; two tolerate the indwelling catheter poorly, and the seventh uses intermittent catheterization with occasional difficulty. CONCLUSIONS: Brachytherapy with or without external irradiation can be associated with severe complications. RUF managed with aggressive anterior pelvic exenteration and urinary diversion can be associated with excellent results. The York-Mason procedure in patients with an adequate urinary continence mechanism and bladder dynamics may provide good functional results. The presence of a secondary malignancy in patients deserves further investigation. Many recurrences of a BNC tend be refractory to transurethral resection/incision; indwelling catheters are then poorly tolerated and patients may require a major reconstructive procedure.

Soft tissue disease.

In the assessment of patients with soft tissue complaints, it is important to consider infectious etiologies in the differential diagnosis, especially in immunocompromised hosts. The exact categorization of some bacterial infections of the soft tissues may be difficult. The structures potentially involved include the skin, subcutaneous tissue, fascia, and skeletal muscle. Classification is usually based upon the anatomic structure involved, the infecting organism, and the clinical picture. The categorization is complicated by the fact that some infections may involve several soft tissue components and multiple bacterial species. In this review, we will cover cutaneous and subcutaneous tissue infections, fasciitis, septic bursitis, tendonitis, and pyomyositis.

Local excision of T2 and T3 rectal cancers after downstaging chemoradiation.

OBJECTIVE: To evaluate the safety and efficacy of local excision in patients with T2 and T3 distal rectal cancers that have been downstaged by preoperative chemoradiation. SUMMARY BACKGROUND DATA: T2 and T3 cancers treated by local excision alone are associated with unacceptably high recurrence rates. The authors hypothesized that preoperative chemoradiation might downstage both T2 and T3 lesions and significantly expand the indications for local excision. METHODS: Local excision was performed after preoperative chemoradiation on patients with a complete clinical response or on patients who were either ineligible for or refused to undergo abdominoperineal resection. Local excision was approached transanally by removing full-thickness rectal wall and the underlying mesorectum. RESULTS: From 1994 to 2000, 95 patients with rectal cancers underwent preoperative chemoradiation and surgical resection for curative intent. Of these, 26 patients (28%), 19 men and 7 women, with a mean age of 63 years (range 44-90), underwent local excision. Pretreatment endoscopic ultrasound classifications included 5 T2N0, 13 T3N0, 7 T3N1, and 1 not done. Pathologic partial and complete responses were achieved in 9 of 26 (35%) and 17 of 26 (65%) patients, respectively. Two of nine partial responders underwent immediate abdominoperineal resection. The mean follow-up was 24 months (median 19, range 6-77). The only recurrence was in a patient who refused to undergo abdominoperineal resection after a partial response. There was one postoperative death from a stroke. This treatment was associated with a low rate of complications. CONCLUSION: Local excision appears to be an effective alternative treatment to radical surgical resection for a highly select subset of patients with T2 and T3 adenocarcinomas of the distal rectum who show a complete pathologic response to preoperative chemoradiation.

Polymyalgia rheumatica and temporal arteritis with sacroiliitis and osteitis pubis.

Polymyalgia rheumatica (PMR) and temporal arteritis (TA) have been associated with a seronegative polyarthritis that can mimic rheumatoid arthritis. Sacroiliitis and osteitis pubis are most often encountered in the different types of spondyloarthropathy. However, sacroiliitis and osteitis pubis have rarely been described in patients with polymyalgia rheumatica and temporal arteritis. We present two patients, one with temporal arteritis and the other with polymyalgia rheumatica, who also had many features of a spondyloarthropathy, including sacroiliitis and osteitis pubis. In reviewing the literature, we found 30 other patients with a diagnosis of PMR who also had sacroiliitis and/or osteitis pubis. We propose that the inflammatory arthritis associated with polymyalgia rheumatica and temporal arteritis can involve the axial joints, resembling a spondyloarthropathy. It is important for the clinician to recognize that sacroiliitis and osteitis pubis have been associated with PMR and TA so that their radiographic presence does not dissuade the clinician from making the correct diagnosis.

Antinuclear antibody-negative, drug-induced lupus caused by lisinopril.

The clinical symptoms of drug-induced lupus (DIL) are similar to those of idiopathic systemic lupus erythematosus. The literature indicates that in patients with DIL, sera generally contain antinuclear antibodies (ANAs); however, ANA-negative DIL has been reported. The list of medications implicated as etiologic agents in DIL continues to grow. This list includes two different types of angiotensin-converting enzyme inhibitors--captopril and enalapril. We report the first case of DIL caused by lisinopril. Our patient had negative results on ANA testing and had histone antibodies (IgG anti-[H2A-H2B]-DNA) mirroring the disease course. Antibodies to the (H2A-H2B)-DNA complex are seen in more than 90% of patients with active DIL, excluding those with DIL due to hydralazine. Thus, it is important to recognize the clinical significance of IgG anti-(H2A-H2B)-DNA antibodies and that negative ANA test results do not preclude the diagnosis of DIL.

Mediastinal lymphadenopathy: a variant of incomplete Kawasaki disease.

A 14-month-old girl presented with a 4-d history of fever and generalized exanthema. Four characteristic symptoms of incomplete Kawasaki disease (KD) were present on admission (fever, rash, non-purulent conjunctival injection, oropharyngeal changes) and then followed by oedema of the hands and feet and mild plantar desquamation. The typical laboratory features of KD, such as elevated erythrocyte sedimentation rate, leukocytosis, thrombocytosis, and positive C-reactive protein were also seen. Ultrasound examination of the mediastinum revealed the presence of a lymph node, 30 mm in diameter, below the tracheal carina. Thoracic CT scan confirmed the mediastinal lymph node. The patient was treated with aspirin and intravenous gamma-globulin. Ultrasound study of the mediastinum, which was carried out 6 weeks after hospital discharge, showed that the lymph node had disappeared. This case illustrates that lymph nodes other than cervical lymphadenopathy should be sought when the diagnosis of classical or atypical KD is suspected.

Squamous-cell carcinoma of the pelvis in a giant condyloma acuminatum: use of neoadjuvant chemoradiation and surgical resection: report of a case.

A 60-year-old bisexual male was referred to our institution for management of an unresectable squamous-cell carcinoma of the pelvis arising in a giant condyloma acuminatum. He received neoadjuvant chemoradiation consisting of 5-fluorouracil and mitomycin C with concurrent external beam radiation, followed by posterior pelvic exenteration. The surgical specimen had no residual cancer. In situ hybridization was performed using a human papilloma virus omniprobe for human papilloma virus subtypes 6, 11, 16, 18, 31, 33, and 35. Two years after diagnosis the patient is doing well with no evidence of recurrent disease.

A 67-year-old woman with polymyalgia rheumatica and left hemispatial neglect.

A 67-year-old woman with a diagnosis of polymyalgia rheumatica presented initially with periods of confusion and incontinence. A CT scan of the brain was normal and she was treated with tapering doses of corticosteroids and clinical improvement. After a brief period off steroids, the patient presented with a progressive dementia, left-sided clumsiness, gait disturbances and left hemispatial neglect. An MRI at this time demonstrated a large area of edema over the right parietal lobe and intense cortical enhancement. A chest CT demonstrated multiple nodules. Biopsies of the lung and brain failed to identify any infectious organisms or malignant tissue. The leptomeningeal biopsy revealed multiple granulomatous areas with central necrosis and hystiocytic cells consistent with idiopathic hypertrophic pachy-meningitis.

[Accidental destruction of a colostomy. Case report]. / Arrancamiento accidental de una colostomía. A propósito de un caso.

The case which we describe in the following article is an example of the application of new advances in stomatology as well as an example of perfect coordination among medical professionals. A basic element for high quality health care. We describe the accidental removal of a loop colostomy with detachment and colaspe of the stoma and the corresponding treatment followed in order to maintain the viability of the stoma. Finally, we mention the advantages obtained in choosing a conservative treatment for this kind of complicated stomas.

CD44V6 expression in human colorectal carcinoma.

CD44 is an adhesion molecule involved in cell-to-cell and cell-to-matrix interactions. This transmembrane glycoprotein exists in either standard or variant forms, originated by alternative splicing. One of the isoforms (CD44V6) has been shown, in some systems, to modify the metastatic potential of tumor cells. To investigate the role of this biomarker as possible prognostic antigen in colorectal cancer, we immunohistochemically analyzed the distribution of CD44V6 expression on formalin-fixed, paraffin-embedded tissues from resected colorectal cancers of 34 patients. The monoclonal antibody VFF7 against the amino acid sequence encoded by exon CD44V6 was applied using the avidin-biotin-peroxidase method. For each resected specimen, normal (N), adenomatous (AD), and carcinomatous (CA) colonic mucosa were tested. In 68% of the resected cases, these areas were present in the same slide, and in 76% of cases, nodal or liver metastases (MT) were available for evaluation. Adenomatous polyp biopsy specimens of 10 carcinoma-free patients were also tested. In selected cases, CD44V6 expression was also determined using the Western blot immunoprecipitation technique. CD44V6 immunoreactivity was detected in 100% of the ADs, and in 91% of CAs, but was mostly weak in only 38% of MTs (n=26). In 49% (n=35) of ADs, 11% (n=34) of CAs, and 4% of MTs (n=26), the stain was moderate to strong. CD44V6 immunoreactivity was predominantly membranous in ADs and cytoplasmic in MTs. In the CAs, both staining patterns were noted. Interestingly, the normal mucosa had a weak subnuclear localization of the stain. In the cases evaluated by Western blotting immunoprecipitation analysis, the level of CD44V6 protein expression was similar to that obtained by immunohistochemistry. No correlation was found with tumor type, stage, or patient survival. The predominant CD44V6 expression in ADs and CAs, but not in MTs, suggests that, in many cases, the expression of this adhesion molecule may be lost during the acquisition of migratory function by the tumor cells.

Polymyalgia rheumatica with a low erythrocyte sedimentation rate: comparison of 10 cases with 10 cases with high erythrocyte sedimentation rate.

Polymyalgia rheumatica (PMR) is an inflammatory disorder characterized by severe proximal myalgias associated with an elevated erythrocyte sedimentation rate (ESR). In this report 10 otherwise typical PMR patients with an ESR <35 mm/hr, and 10 PMR patients with an ESR > 35 mm/hr were examined and prospectively followed. We report the initial laboratory response to steroids in both groups as well as follow-up (average32.6 months in the low ESR group). The average follow-up for this study is the longest reported for low ESR PMR. The most significant difference noted was a longer duration before diagnosis and therapy for the low ESR group. Both groups showed similar clinical and laboratory response to therapy and similar post-treatment disease duration.The absence of an elevated ESR does not exclude the diagnosis of PMR. Clinical response to steroids and a drop in the ESR after therapy are proposed as useful to confirm the diagnosis.

Avoiding Colostomy With Conservative Multimodality Management of Distal Rectal Cancer.

While abdominoperineal resection with permanent colostomy has been the surgical benchmark in the treatment of distal rectal carcinoma, different approaches to treatment have been sought for decades to decrease the morbidity and mortality associated with radical surgical procedures for this disease. The advent of alternative methods of sphincter preservation that afford excellent functional results has led to a decline in the incidence of abdominoperineal resection. With appropriate patient selection, accurate preoperative staging data, and the selection of a surgical approach appropriate to the tumor stage, conservative surgical approaches now can be considered in the treatment of cancer at every level of the rectum.

ACTH revisited: effective treatment for acute crystal induced synovitis in patients with multiple medical problems.

OBJECTIVE: To determine the effectiveness of adrenocorticotropic hormone (ACTH) for acute gouty arthritis and pseudogout in a population of patients with multiple coexisting medical problems. METHODS: We retrospectively reviewed our experience with parenteral ACTH 40 or 80 units intravenous, intramuscular, or subcutaneous tid with tapering in the treatment of 38 patients. Thirty-three patients had documented acute gout and 5 patients had documented acute pseudogout. A total of 43 episodes of acute crystal induced synovitis were treated. The indications for using ACTH included congestive heart failure, chronic renal insufficiency, gastrointestinal bleeding, or no response to NSAID: RESULTS: All episodes of pseudogout resolved in an average of 4.2 days. Of the episodes of acute gout, 97% resolved in an average of 5.5 days. Although mild hypokalemia, hyperglycemia, fluid retention and rebound arthritis occurred as adverse effects, none was severe and all were easily controlled. CONCLUSION: ACTH is a safe and effective treatment for acute gout and pseudogout, especially in patients with multiple medical problems.

The absence of factor B activation products in scleroderma.

Previous investigators have reported the presence of complement activation products in scleroderma. Using an assay consisting of isoelectric focussing followed by immunofixation (IEF/IF) for alternative pathway activation product Ba, and an ELISA for C3d that we developed for evaluating lupus plasmas, we assayed 48 plasmas from patients with diffuse cutaneous scleroderma, 16 patients with the limited CREST variant, 2 patients with mixed connective tissue disease (MCTD) and 4 patients with Raynaud's disease. Ba was not detected in any patient's plasma. Only one plasma from a patient with CREST contained elevated levels of C3d. We cannot reconcile the absence of B activation products in our patients with scleroderma with the results of the previous report, and conclude that further studies are necessary.

Treatment of Wegener's granulomatosis with sulfamethoxazole-trimethoprim.

Sulfamethoxazole-trimethoprim may be an alternative or adjunctive treatment for Wegener's granulomatosis, as suggested by our experience with six patients. Two had limited Wegener's granulomatosis; one of these achieved remission with sulfamethoxazole-trimethoprim alone, and the second achieved remission with sulfamethoxazole-trimethoprim and prednisone. Four patients presented with sinus, pulmonary, and renal involvement. One patient initially treated with sulfamethoxazole-trimethoprim developed worsening renal function requiring cytotoxic therapy. Two patients initially treated with cytotoxic agents achieved remission coincident with the addition of sulfamethoxazole-trimethoprim for persistent sinus symptoms. One patient had relapse of pulmonary symptoms after achieving and maintaining a remission during treatment with sulfamethoxazole-trimethoprim alone. This experience suggests that sulfamethoxazole-trimethoprim may be an effective treatment for some patients with Wegener's granulomatosis and may be the only agent required. Patients require careful follow-up and still may need cytotoxic therapy.

Myonecrosis and myofibrosis as complications of sickle cell anemia.

Painful crises in sickle cell anemia are associated with infarction and subsequent fibrosis of many different organs. Myonecrosis secondary to muscle infarction during a crisis and subsequent fibrosis are often not recognized as complications of sickle cell anemia. We describe four patients, all of whom had recurrent episodes of symmetric proximal muscle pain and swelling as prominent features of their crises. Muscle biopsies showed acute myonecrosis with a minimal inflammatory reaction as well as myofibrosis with abundant collagen deposition. Chronic sequelae consisted of muscle induration, atrophy, and contractures.