BMI: does it predict the need for component separation?

PURPOSE: Patient optimization and selecting the proper technique to repair large incisional hernias is a multifaceted challenge. Body mass index (BMI) is a modifiable variable that may infer higher intra-abdominal pressures and, thus, predict the need for component separation (CS) at the time of surgery, but no data exist to support this. This paper assesses if the ratio of anterior-posterior (AP): transverse (TRSV) abdominal diameter, from pre-operative CT imaging, indicates a larger proportion of intra-abdominal fat and correlates with a hernia defect requiring a component separation for successful tension-free closure. METHODS: Ninety patients were identified who underwent either an open hernia repair with mesh by primary closure (N = 53) or who required a component separation at the time of surgery (N = 37). Pre-operative CT images were used to measure hernia defect width, AP abdominal diameter, and TRSV abdominal diameter. Quantitative data, nominal data, and logistic regression was used to determine predictors associated with surgical group categorization. RESULTS: The average hernia defect widths for primary closure and CS were 7.7 ± 3.6 cm (mean ± SD) and 9.8 ± 4.5, respectively (p = 0.015). The average BMI for primary closure was 33.9 ± 7.2 and 33.8 ± 4.9 for those requiring CS (p = 0.924). The AP:TRSV diameter ratios for primary closure and CS were 0.41 ± 0.08 and 0.49 ± 0.10, respectively (p < 0.001). In a multivariate analysis including both defect width and AP:TRSV diameter ratio, only AP:TRSV diameter ratio predicted the need for a CS (p = 0.001) while BMI did not (p = 0.92). CONCLUSION: Intraabdominal fat distribution measured by AP:TRSV abdominal diameter ratio correlates with successful tension-free fascial closure during incisional hernia repair, while BMI does not.

Changes in neuromuscular activity during motor training with a body-machine interface after spinal cord injury.

Body machine interfaces (BMIs) are used by people with severe motor disabilities to control external devices, but they also offer the opportunity to focus on rehabilitative goals. In this study we introduced in a clinical setting a BMI that was integrated by the therapists in the rehabilitative treatments of 2 spinal cord injured (SCI) subjects for 5 weeks. The BMI mapped the user's residual upper body mobility onto the two coordinates of a cursor on a screen. By controlling the cursor, the user engaged in playing computer games. The BMI allowed the mapping between body and cursor spaces to be modified, gradually challenging the user to exercise more impaired movements. With this approach, we were able to change our subjects' behavior, who initially used almost exclusively their proximal upper body-shoulders and arms - for using the BMI. By the end of training, cursor control was shifted toward more distal body regions - forearms instead of upper arms - with an increase of mobility and strength of all the degrees of freedom involved in the control. The clinical tests and the electromyographic signals from the main muscles of the upper body confirmed the positive effect of the training. Encouraging the subjects to explore different and sometimes unusual movement combinations was beneficial for recovering distal arm functions and for increasing their overall mobility.

[Intestinal intussusception: easy diagnosis in the 21st Century? Outcome of five years experiences]. / Invaginazione intestinale: una diagnosi facile nel 21 degrees secolo? Outcome degli ultimi 5 anni.

UNLABELLED: Intussusception is an entity well codify in pediatric surgery, with guidelines well defined since years in terms of imaging and procedures. MATERIAL: From January '99 to Dec. '03, 25 children were admitted to the Department of Pediatric Surgery of the Children's Hospital of Milan. All the aspects related to the pathology have been evaluated in the study. RESULTS: 25 patients have been studied. 23/25 presented severe pain, 19/25 normal bowel movements in the last 3 hours and in 9/25 a mass were detected at clinical examination.19/25 were submitted to laparotomy after failure of reduction through barium enema, and in 17/19 a manual reduction were performed. Only 2 patients required a bowel resection with primary anastomosis. The analysis of the delay of diagnosis, the delta-T between beginning of the symptoms and first medical evaluation was of 16,23 h. (3-72), and the delta-T between the first evaluation and diagnosis was 18,7 h. The interval between diagnosis and surgery was of 4,3. CONCLUSION: Authors believe that intussusception still represent a challenge for medical and surgical emergency team, supported by the data in literature. Imaging procedures must not be constricted in case of minimal suspicions of intestinal intussusception.

[Cystic tumours of the pancreas]. / Tumori cistici del pancreas.

The authors illustrate 2 cases of cystic pancreatic neoplasms recently observed at the 2nd Surgical Clinic of IRCCS Policlinico San Matteo in Pavia. Having emphasised the rarity of this pathology, they describe the specific nature of the clinical condition and symptoms which may remain unchanged for a long period. They then highlight the most significant radiological aspects, paying special attention to differential diagnosis. Surgery is indicated as the treatment of election, correlated to the topography of the lesion, the anatomic and histological nature of the disease, especially mucinous, and the patient s general conditions.

Absence of PTEN repeat tract mutation in endometrial cancers with microsatellite instability.

OBJECTIVE: PTEN, a tumor suppressor gene shown to be frequently mutated in endometrial cancers, has been suggested to be a target of microsatellite instability (MSI)-driven mutagenesis. We set out to investigate the relationship between MSI and PTEN mutation in a large series of primary endometrial carcinomas. METHODS: Thirty-nine MSI-positive endometrial cancers were evaluated by single-strand conformational variant analysis and direct sequencing to screen all nine PTEN exons for mutation. RESULTS: Fifteen specimens (38%) demonstrated 16 PTEN mutations. We observed only one alteration in the poly-adenine repeat of exon 8 that is suggested to be a target for mutation in endometrial cancers with MSI. Seven of 16 (44%) mutations in our series were deletions of >/=3 bp, a class of mutation not usually associated with tumors with defective DNA mismatch repair. To determine the significance of this high frequency of deletion, 26 additional endometrial cancers without MSI were matched with the 39 MSI-positive cancers for the prognostic factors of tumor histology, stage, grade, and patient race. The MSI-positive tumors had a significantly higher frequency of deletions involving >/=3 bp when compared with the MSI-negative group (5/11 versus 0/10, P = 0.035). CONCLUSIONS: Repeat tract mutation in PTEN is an uncommon event in MSI-positive cancers. Deletion of >/=3 bp in this gene is more common in MSI-positive cancers when compared with tumors without MSI.

Ca2+/phospholipid-binding and syntaxin-binding of native synaptotagmin I.

Synaptotagmin, a synaptic vesicle protein endowed with multiple properties, is the putative calcium sensor in neuroexocytosis. Ca2+/phospholipid binding and syntaxin binding activity of synaptotagmin were previously investigated using recombinant fusion proteins. In phospholipid binding the EC50 for calcium obtained was different when fusion proteins containing one (C2A) or both (C2A+C2B) binding domains were used. It was alternatively proposed that one or both synaptotagmin binding domains are important for calcium-sensing and triggering of transmitter release. In this study the binding activity of native full-length synaptotagmin, immobilized on beads, was investigated. We found the kinetic parameters of Ca2+/phospholipid binding to be compatible with the role of calcium sensor for synaptotagmin (EC50 for calcium = 72 +/- 7 microM), with the two C2 domains supporting separate and complementary calcium sensing properties. The binding of native syntaxin to synaptotagmin was measurable in the absence of calcium, but was markedly stimulated (2.2-fold) in the presence of mM calcium. It may be speculated that the two domains have a synergistic action in fast synchronous transmitter release, whereas C2B domain alone may support slow asynchronous release, working as a high affinity calcium sensor.

Long-term blockade of serotonin reuptake affects synaptotagmin phosphorylation in the hippocampus.

Synaptic vesicle trafficking and transmitter release from presynaptic terminals are precisely regulated by a complex array of protein/protein interactions. Several of these proteins are substrates of endogenous protein kinases present in presynaptic terminals. The activity of Ca2+/calmodulin-dependent protein kinase II(CaMKII), one of the kinases involved in the modulation of transmitter release, was previously shown to increase in the hippocampus after long-term blockade of 5-hydroxytryptamine (5-HT) reuptake (a treatment known to elicit an increase in 5-HT release in this area). To investigate the changes induced in presynaptic protein phosphorylation by 5-HT reuptake blockade and concomitant CaMKII up-regulation, we analyzed two major CaMKII presynaptic substrates (synapsin I and synaptotagmin). All 5-HT reuptake blockers that we used, which induce an increase in CaMKII activity and autophosphorylation, also caused a large (2-3-fold) increase in the Ca2+/calmodulin-dependent post hoc phosphorylation of synaptotagmin. Conversely, the phosphorylation of synapsin I is much less affected. The change in synaptotagmin phosphorylation, as determined through immunoprecipitation and quantitative immunoblot analysis after fluvoxamine treatment, is due exclusively to increased phosphate incorporation (presumably caused by the increased kinase activity) and not to a change in the level of substrate protein after the treatment. Thus, drugs known to induce an increase in 5-HT release simultaneously induce an increase in the activity of presynaptic CaMKII and in the phosphate incorporation (post hoc) by a major CaMKII substrate in synaptic vesicles (synaptotagmin). This finding establishes a link between the facilitation of transmitter release induced by antidepressant drugs and the phosphorylation of synaptotagmin by CaMKII.

[Malignant fibrous histiocytoma of the breast. A clinical case]. / Istiocitoma fibroso maligno della mammella. Contributo clinico.

The authors report a personal, observed case of relapsing malignant fibrous histiocytoma of the breast. After recalling the anatomopathologic aspects and the clinical characteristics of the affection, the authors dwell upon the utility of correct diagnosis and point to the right therapeutic way consisting of a radical surgical treatment.

[Primary osteogenic sarcoma of the breast. Clinical contribution]. / Sarcoma osteogenico primitivo della mammella. Contributo clinico.

A case of primary osteogenic sarcoma of the breast is reported. All its clinical, radiological, gross and histological characteristics are analyzed, nevertheless the diagnosis is difficult. The authors dwell upon the utility of fine-needle aspiration and upon the importance of histologic and immunohistochemical studies. After emphasizing the difficulty both in an adequate local control and of metastasis, the authors point to the right therapeutic ways, still debated for the rarity of the tumor, which precludes every prospective trial.

[Intestinal occlusion caused by actinic ileitis]. / L'occlusione intestinale da ileite attinica.

During the 5-year period from 1988 to 1992, 6 patients underwent operation for radiation-induced small bowel obstruction at the General Surgery II, IRCCS Policlinico S. Matteo of Pavia. Based on this experience and reports in the literature, physiopathology, pathologic findings, and operative technics are discussed.

A Mutant of Arabidopsis thaliana with a Reduced Response to Fusicoccin. I.

Because fusicoccin (FC) has the the capacity to promote solute uptake, a selective procedure for isolating mutants of Arabidopsis thaliana with a reduced response to the toxin has been developed. The procedure is based on the incubation of A. thaliana seedlings in a solution containing the cation Paraquat (Pq) at a concentration that per se does not produce bleaching of the leaves upon illumination but does in the presence of FC because of the increased uptake of the toxic cation. Using this procedure, we identified, among the progenies of 2010 M1 ethyl methanesulfonate-mutagenized plants, two mutants that stay green after exposure to FC and Pq. Some properties and inheritance of one of the two mutants (5-2) are described. Morphology of mutant plants is almost indistinguishable from that of the wild type. However, 5-2 seeds germinate and produce viable seedlings in the presence of FC plus the aminoglycoside antibiotic hygromycin B: plants of the mutant do not wilt when exposed to FC and stomata do not open or open only partially. In the presence of FC, the mutant appears less responsive than the wild type as far as the increment in fresh weight, the enlargement of leaf disc area, or the stimulation of H+ extrusion is concerned. Inheritance of the trait is monogenic dominant or semidominant, depending on the test used.

[Primary non-Hodgkin's lymphoma of the breast. Clinico-pathologic study of 2 cases]. / Linfomi non-Hodgkin primitivi della mammella. Studio clinico-patologico di due casi.

The authors describe two cases of malignant non-Hodgkin's lymphoma in a mammary site observed at IRCCS Policlinico San Matteo (Pavia). Histologic, immunohistochemical and clinical features are illustrated. Correct diagnosis is essential so that appropriate multidisciplinary treatment may be applied.

[Sigmoid volvulus]. / Considerazioni sul volvolo del sigma.

The authors report a retrospective study of four patients treated for sigmoid volvulus at the Clinica Chirurgica II of IRCCS Policlinico S. Matteo of Pavia between April 1974 and June 1989. They are collected from a series of 74 consecutive operations for colonic obstruction not related to hernias of the inguinal-crural region (incidence 5.4%). One patient died. The authors review the incidence, epidemiology, etiopathogenetic hypothesis, clinical patterns, nonoperative and operative therapeutic options of the affection. They emphasize the poor prognosis because the sigmoid volvulus usually occurs in elderly ill patients.

[Acute pseudo-obstruction of the colon (clinical cases)]. / La pseudo-ostruzione acuta del colon (contributo casistico).

The Authors report 4 cases of Ogilvie's syndrome come to their observation during the last 5 years by the clinical surgery II of the I.R.C.C.S. Polyclinic "San Matteo" of Pavia. Remembering the infrequency of the affection and the controversial etiopathogenesis theories, the Authors study the clinical picture and the diagnostic problems, pointing out how some researches, especially radiological and endoscopical, permit to obtain a therapeutic solution of the syndrome. They underline the colonic perforation risk, certainly overestimated, and they show the therapeutic, medical or surgical, orientations, according to the evolution of the illness, the anatomic situations and the general conditions of the patient.

Ethanol-Induced Activation of ATP-Dependent Proton Extrusion in Elodea densa Leaves.

In Elodea densa leaves, ethanol up to 0.17 m stimulates H(+) extrusion activity. This effect is strictly dependent on the presence of K(+) in the medium and is suppressed by the presence of the plasmalemma H(+)-ATPase inhibitor vanadate. Stimulation of H(+) extrusion is associated with (a) a decrease in cellular ATP level, (b) a marked hyperpolarization of transmembrane electrical potential, and (c) an increase in net K(+) influx. These results suggest that ethanol-induced H(+) extrusion is mediated by an activation of the plasma membrane ATP-dependent, electrogenic proton pump. This stimulating effect is associated with an increase of cell sap pH and of the capacity to take up the weak acid 5,5-dimethyloxazolidine-2,4-dione, which is interpretable as due to an increase of cytosolic pH. This indicates that the stimulation of H(+) extrusion by ethanol does not depend on a cytosolic acidification by products of ethanol metabolism. The similarity of the effects of ethanol and those of photosynthesis on proton pump activity in E. densa leaves suggests that a common metabolic situation is responsible for the activation of the ATP-dependent H(+)-extruding mechanism.

[Epithelial cysts of the spleen]. / Considerazioni sulle cisti epiteliali della milza.

The Authors report a case of epithelial cyst of the spleen-observed in a 25 years old woman. After remembering the nomenclature and pathogenetic hypothesis, they consider clinical patterns of this rare disease of the spleen which is usually found in children and young adults. The Authors discuss pathological findings, diagnostic aids, especially non-invasive imaging. They also suggest considering the cysts in diagnosis of the diseases of the spleen and splenectomy as a treatment of choice.

[The surgery of liver trauma (clinical contribution)]. / La chirurgia dei traumi epatici (contributo clinico).

Authors perform a retrospective review of all hepatic injuries operated on between 1974 and 1990 at Clinica Chirurgica II (ex Patologia Chirurgica II, ex Semeiotica Chirurgica) of Policlinico San Matteo (IRCCS) of Pavia. Thirteen patients were treated, 9 men and 4 women, with age ranged from 13 to 68 years and a mean age of 38 years. They were 21% of all patients operated on for abdominal trauma. Penetrating wounds were present in only two cases (15%), the other patients (85%) were affected by blunt trauma. The mechanisms of injuries were: road accidents (77%), fall at work (8%), gun shot wound (8%), stab wound (8%). All patients had associated injuries. The mortality was 31%: one patient died for haemorrhagic shock and the other three for craniocerebral injuries. After reviewing the several haemostatic techniques advocated for the various types of hepatic injuries, the authors stress that, although most lesions are minor and can be managed by simple technique of haemostasis, often the prognosis is severe for the associated injuries.

[Carcinoma of the male breast (case contributions)]. / Il carcinoma della mammella maschile (contributo casistico).

Authors refer about their experience on 12 cases of male breast carcinoma (MBC), studied in years 1975-1985 at the Semeiotica Chirurgica e Patologia Chirurgica II dell'I.R.C.C.S. Policlinico S. Matteo of Pavia. After a thorough discussion of the etiopathologic factors, there are cited the most common histotypes of MBC, as well as the typical clinical aspects, of basic importance for the compilation of the diagnostic inquiry, which, in uncertainty, makes use of the acuaspiration and of the excisional biopsy, there is referred on the present therapeutic trends, and results of their casuistry are exposed.

[Biliary ileus]. / Considerazioni sull'ileo biliare.

The authors report a retrospective review of four cases of gallstone ileus seen at Semeiotica Chirurgica, at Patologia Chirurgica II and Clinica Chirurgica II of Policlinico San Matteo I.R.C.C.S. of Pavia between 1974 and 1989. Three patients were women and one male, with average age 69.4 years. All obstructions occurred in the distal ileum. Proceeding from available data in the literature and from their personal experience the Authors emphasize that gallstone ileus is a rare cause of mechanical obstruction of intestine (4% of the obstructions of the small bowel). This disease usually occurs in elderly women, with concomitant illness. Approximately 50 per cent of the patients have an history of gallbladder disease. The authors discuss the controversy on performing an enterolithotomy alone versus one stage procedure consisting of removal of the impacted stone, fistula repair and cholecystectomy. The prognosis is severe. High mortality and many postoperative complications are caused by the advanced age of the patients, concomitant illness and usually delayed diagnosis.

[An unusual cause of intestinal occlusion: endometriosis of the sigmoid]. / Una rara causa di occlusione intestinale: l'endometriosi del sigma.

Colo-rectal endometriosis involving extensive intestinal wall may result in obstruction. This report is based on two patients having symptomatic intestinal endometriosis that required operative treatment. Diagnostic, pathologic and therapeutic findings were reviewed. Current treatment is the removal of the endometriomas, while removal of the reproductive organs should be made only after evaluation on the patient's menstrual status, age and future pregnancy desire.