Patellar Tendon Reconstruction for a Chronic Extensor Mechanism Deficit Using an Achilles Tendon Allograft With Hamstring Autograft and Suture Augmentation.

Patellar tendon ruptures are the third most common injury to the extensor mechanism. These injuries are debilitating to the patient, and delays in treatment can present a challenge to the treating surgeon. Chronic patellar tendon injuries are rare and are more difficult to manage given proximal patellar retraction, scarring, and atrophy of surrounding tissues. There is no consensus on the optimal approach for treatment, and numerous reconstruction techniques have been described using a variety of graft choices and fixation methods. We describe our surgical technique for a 3-fold reconstruction of a chronic patellar tendon rupture using an Achilles tendon allograft augmented with a vascularized ipsilateral hamstring tendon autograft and additional FiberTape augmentation. The aim of this procedure is to restore patellar height and prevent extensor lag.

Comparative Analysis of Indices in the Study of Virulence Diversity Between and Within Populations of Puccinia recondita f. sp. tritici in Israel.

ABSTRACT Isolates of Puccinia recondita f. sp. tritici (n = 260) obtained from bread, durum, and wild emmer wheat leaf collections throughout Israel during 1993 to 1997 were analyzed for virulence on a set of wheat differentials. The overall frequency of virulence increased on differentials possessing resistance genes Lr1, Lr2a, Lr3, and Lr26 and decreased on Lr17, Lr21, and Lr30. Genes Lr9 and Lr24 were resistant, while Lr18 was susceptible (98% in 1996) to all tested leaf rust isolates and Lr10 and Lr23 were susceptible to more than 78% of the isolates. Diversity between populations (years) was assessed using Kosman's H(KB) (based on degrees of similarity among distinct phenotypes) and H(KDis) (based on frequencies of individual virulences) and Nei's and Rogers' distances. The greatest difference occurred between the 1993 and 1994 populations. Phenotypic diversity within each population (year) was analyzed using the Shannon's, Simpson's, and Kosman's indices. The highest diversity within years was recorded in 1994 and significantly increased from 1993 to 1994 for all indices. The variance in the diversity between populations can be only partially explained by differences between corresponding diversities within population. The comparative analysis of diversity between and within populations over the 5 years enabled a detailed study of changes in the pathogen population. The results show that the different measures do not yield the same rank order of diversity.

Elucidation of Septoria tritici x Wheat Interactions Using GUS-Expressing Isolates.

ABSTRACT Isolate ISR398 of Septoria tritici (which produces none to few pycnidia on the wheat cv. Seri 82 and high coverage on cv. Shafir) and isolate ISR8036 (which is virulent on both cultivars) were genetically cotrans-formed using the selectable marker gene hph, which confers resistance to hygromycin B (hygB), and the reporter gene uidA, encoding beta-glucuronidase (GUS). Most of the genetically transformed isolates (98.8%) produced similar pycnidial coverage on seedlings of 'Seri 82' and 'Shafir' as the two wild-type isolates. Southern analysis of 25 randomly selected hygB(R)GUS(+) transformants probed with the uidA sequence revealed multiple insertion sites. GUS activity was determined fluorimetrically by measuring the conversion of 4-methylumbelliferyl beta-D-glucuronide (MUG) to 4-methylumbelliferone (MU). The high GUS-expressing transformants 398D97 and 8036E27 were used to elucidate fungal development within inoculated leaf tissue by using GUS activity to estimate the fungal proteins content in planta. Increase in fungal biomass was recorded in 'Shafir' inoculated with the GUS-expressing transformants 398D97 and 8036E27 following a 12-day latent period. A 15-day latent period was recorded in 'Seri 82' inoculated with 8036E27, whereas an 18-day latent period was recorded on 'Seri 82' inoculated with 398D97 and the two mixtures 398D97 + ISR8036 and ISR398 + 8036E27. The rate of fungal development and the estimated level of fungal proteins at the pycnidia maturation stage was high in leaves of 'Shafir' and moderate to low on 'Seri 82', even in cases in which no significant differences were recorded in pycnidial coverage. An endogenous capacity to hydrolyze beta-1,4-D-glucuronidase was recorded in leaves inoculated with wild-type isolates. The latent periods in MU production of the uidA-expressing transformants mimicked those recorded for the wild-type isolates. However, at all stages, the levels of MU produced in wheat inoculated with wild-type isolates were markedly lower than those produced by GUS-expressing transformants. The mode of interaction (compatible or incompatible) determined the onset of the induction, rate, and level of enzyme production.

Physiological Aspects Related to Tolerance of Spring Wheat Cultivars to Septoria tritici Blotch.

ABSTRACT The susceptible wheat cultivar Miriam exhibited tolerance under severe infection of Septoria tritici blotch (STB). Nethouse and greenhouse trials confirmed former field results in which losses in grain weight of 'Miriam' wheat due to STB infection were significantly lower than those of the susceptible cultivar Barkai, under equivalent severity and the same disease progress curve. Several physiological mechanisms that may explain this tolerance of 'Miriam' wheat were studied. A comparison between protected and infected plants proved that carbohydrate reserves in the culms and other vegetative plant parts did not account for the lower losses in grain weight of 'Miriam'. Each tiller was shown to be independent in its supply of carbohydrates to its grains, and no import from secondary tillers was observed. Differences in the ratio between grain weight and vegetative biomass could not explain the sustained grain filling of infected plants of 'Miriam'. The daily balance of CO(2) exchange of the ears was negative, since carbon fixation by the spike in the light was more than counterbalanced by night time spike respiration. Radioisotope studies revealed that mature, infected 'Miriam' plants maintained as large a percentage of the carbohydrates fixed at the vegetative stage and early grain filling as healthy plants. On the other hand, under the same conditions, infected 'Barkai' plants lost a larger fraction of these carbohydrates. The rate of carbon fixation per unit of chlorophyll and per residual green leaf area of infected 'Miriam' was higher than in healthy plants. It is proposed that this enhancement of photosynthesis in residual green tissue of infected plants of the tolerant cultivar Miriam compensates for the loss of photosynthesizing tissue due to STB.

Purification and characterization of a catalase-peroxidase from the fungus Septoria tritici.

Three classes of heme proteins, commonly designated hydroperoxidases, are involved in the metabolism of hydrogen peroxide: catalases, peroxidases, and catalase-peroxidases. While catalases and peroxidases are widely spread in animals, plants, and microorganisms, catalase-peroxidases were characterized only in prokaryotes. We report here, for the first time, on a catalase-peroxidase in a eukaryotic organism. The enzyme was purified from the fungal wheat pathogen Septoria tritici, and is one of three different hydroperoxidases synthesized by this organism. The S. tritici catalase-peroxidase, designated StCP, is similar to the enzymes previously isolated from the bacteria Rhodobacter capsulatus, Escherichia coli, and Klebsiella pneumoniae, although it is significantly more sensitive to denaturing conditions. In addition to its catalatic activity StCP catalyzes peroxidatic activity with o-dianisidine, diaminobenzidine, pyrogallol, NADH, and NADPH as electron donors. The enzyme is a tetramer with identical subunits of 61,000 Da molecular weight. StCP shows a typical high-spin ferric heme spectrum with a Soret band at 405 nm and a peak at 632 nm, and binding of cyanide causes a shift of the Soret band to 421 nm, the appearance of a peak at 537 nm, and abolition of the peak at 632 nm. Reduction with dithionite results in a decrease in the intensity of the Soret band and its shift to 436 nm, and in the appearance of a peak at 552 nm. The pH optimum is 6-6.5 and 5.4 for the catalatic and peroxidatic activities, respectively. Fifty percent of the apparent maximal activity is reached at 3.4 mM and 0.26 mM for the catalatic and peroxidatic activities, respectively. The enzyme is inactivated by ethanol/chloroform, and is inhibited by KCN and NaN3, but not by the typical catalase inhibitor 3-amino-1,2,4-triazole.

Nonoperative management of blunt splenic trauma in adults.

Forty-five adult patients with traumatic splenic injuries were treated during a 6-year period between 1980-1986 at Hadassah Hospital. The diagnosis was confirmed by splenic scintigraphy with 99mTc Tin-colloid. Fifteen patients (33%) who were stable on admission or after initial resuscitation were treated non-operatively and selected for this study. Treatment consisted of careful hemodynamic monitoring, strict bed rest, nasogastric suction, and i.v. fluids. In no case was emergency laparotomy necessary for deterioration of clinical condition or late complications. Splenic scans were repeated in 11 of the patients to assess resolution. In six of the patients, minimal residual defects were detected with no further complications. It is concluded that nonoperative treatment of splenic injuries in carefully selected patients is both safe and effective.

A simplified one stage modification of portoazygos disconnection for massive variceal hemorrhage.

A one stage, complete abdominal portoazygos disconnection procedure is a safe and efficient method for the treatment of acute variceal bleeding. This method was performed upon five patients who were bleeding due to severe cirrhosis of the liver, with no operative mortality. No recurrence of bleeding occurred during a follow-up study of one to four years.

Determinants of wound infection after colon surgery.

Over a period of 54 months, every patient undergoing colon surgery at the Hadassah University Hospital in Jerusalem was followed up prospectively by the same nurse epidemiologist. A total of 403 patients completed the analysis. Risk factors for postoperative wound infection were explored in an epidemiological study, using both single and multivariate analysis. Of the 13 potential risk factors investigated, the four showing the highest association with wound infection were: the performance of more than one operation during a single admission; Arab ethnicity; the use of open drains; and the performance of a colostomy. In patients undergoing more than one operation, the risk for infection was greater if the second operation followed a surgical complication than if it was performed as an elective second procedure; whether the first operation was elective or not did not affect the infection rate. Second operations performed within 7 days of the first carried a higher risk for infection than those performed later. The different prophylactic protocols used during the period of investigation did not have an independently significant contribution to the risk of infection.

Amputation neuroma of common bile duct with obstructive jaundice: a case report.

A 67-year-old woman was hospitalized because of recurrent attacks of epigastric pain, chills, fever, jaundice and pruritus of 6 months' duration. Six years earlier, the patient had undergone cholecystectomy. The present endoscopic retrograde cholangiopancreatography demonstrated a proximal irregular choledochal stricture. Resection of the stricture with end-to-end anastomosis was performed. Histological examination of the surgical specimen revealed an amputation neuroma.

Surgical aspects of multifocal involvement of the gastrointestinal tract in progressive systemic sclerosis.

An operative approach to the problem of progressive systemic scleroderma, affecting both the esophagus and duodenum, is demonstrated in the case of a 38-year-old woman severely incapacitated by protracted vomiting. Nissen's fundoplication, antrectomy and Billroth II gastroenterostomy were performed. The need for a comprehensive balanced surgical therapeutic approach in patients suffering from scleroderma is emphasized.

The continuing clinical enigma of duodenal diverticulum.

Seventy-one cases of duodenal diverticula were reviewed. Fifty-four or 76 percent were associated with symptoms of varying severity. Forty (74 percent) of the symptoms were considered serious. These included bleeding, severe abdominal pain, weight loss, chills, fever and jaundice, and evidence of right upper quadrant peritonitis. Nineteen patients were operated on and gallstones were found in 12. Multiple operative procedures because of recurring symptoms characterized the entire series. Relief of symptoms was achieved only in those who had diverticulectomy or a sidetracking operation. The difficulties of identifying this lesion as the source of the patient's symptoms and the indications for its removal are emphasized.

Spontaneous midesophageal rupture.

Spontaneous rupture of the esophagus is rare. To date, 17 such cases, including our patient, have been reported in the literature. We present a case of true spontaneous rupture that occurred during sleep. Because the correct diagnosis was made 36 h after the rupture, treatment consisted of surgical drainage only. The drainage was extrapleural, though a posterior mediastinal approach, thereby avoiding the complication of empyema. The paraesophageal abscess was repeatedly irrigated with povidone-iodine solution. The patient recovered after a long period--56 days--of hospitalization. The report includes a review of the signs and symptoms of esophageal perforation, the current mode of therapy, and some speculation on the pathogenesis of true spontaneous perforation.

Choledochoduodenostomy in the treatment of benign biliary tract disease.

Recurrent surgical interventions on the biliary system for benign biliary tract diseases carry high morbidity and mortality. Choledochoduodenostomy creates a large and easily performed biliodigestive anastomosis enabling good drainage of the biliary system. Among 27 patients undergoing choledochoduodenostomy for benign biliary tract diseases, recurrent cholangitis occurred in only one patient, in whom a stenosed anastomosis was probably the culprit. The other patients have been free of abdominal complaints, cholangitis, or pancreatitis for follow-up periods of from six months to eight years. There was no operative mortality; morbidity was 45%, but hospital stay averaged only 14.7 days. The traditional objections to this procedure do not seem valid where choledochoduodenostomy is rightly indicated, the common bile duct is dilated, and a wide enough anastomosis is constructed. Our favorable results mark choledochoduodenostomy as a safe, simple, and effective procedure in the management of benign biliary tract disease, particularly in the high risk patient.

The role of hypovolemic stress in the production of fat embolism in rabbits. 1. Morphologic alterations of the lungs.

In rabbits, an experimental model of fat embolism was produced that simulates the course of events in the clinical situation. Small doses of fat-cell suspension (0.075 ml/kg of body weight), prepared by collagenase treatment of homologous adipose tissue, were injected intravenously. Concomitantly, hypovolemia was produced in two animal groups by either withdrawing 20 percent of the estimated blood volume or by application of a hind-limb ischemic tourniquet for 90 minutes. The presence of pathoanatomic characteristics typical of fat embolism was evaluated by recording lung/body weights, macroscopic appearance, and semiquantitative microscopic estimation in the lungs of edema, hemorrhage, atelectasis, intravascular coagulation, and leukocytic thrombi. Mean indices of lung/body weight were higher in all animals receiving injections of fat-cell suspension, as compared to controls. The score for microscopic generalized pulmonary damage was significantly higher in rabbits exposed to both fat-cell injections and hypovolemia than in controls or after fat-cell injections alone. It is concluded that hypovolemia enhances the development of fat embolism in rabbits subjected to small doses of fat-cell suspension.

Breast cancer arising in surgical scars.

Twelve women who developed breast cancer at the site of old surgical scars in the breast are presented. Six had had former breast biopsies, 3 drainage of breast abscesses, and 3 developed breast cancer in old thoracotomy scars transversing the breast. The combination of trauma as an oncogen and scar tissue as a functional and immunological locus minoris resistentia seems to play a major role in the development of breast cancer in this group of patients. The associaton of breast cancer, scar, and trauma would not be coincidental. Increased attention drawn to this entity may lead to a rise in the number of cases diagnosed among patients with breast scars after biopsies, abscesses, trauma, or foreign body implantation.

The acute effect of pulmonary burns on lung mechanics and gas exchange in the rabbit.

To determine the role of the thermal element in the production of lung injury uncomplicated by the inhalation of fumes and soot, 18 anaesthetized, paralysed and ventilated rabbits were subjected to a steam burn of the respiratory tract. Transpulmonary pressure (difference between airway and pleural pressure) was recorded under static conditions between functional residual capacity and 40 ml above this point and the values obtained were used to calculate lung compliance. Static compliance decreased progressively with time in each of the experimental animals, the maximum decrease occurring within the 1st hour. Ten of the 18 animals died within 4 hr of the burn. There was little impairment of gas exchange. This data would suggest the clinical value of the early measurement of lung compliance in the evaluation of thermal pulmonary burns. Postmortem studies showed the presence of pulmonary oedema with intra-alveolar peribronchial and perivascular haemorrhages. The lesions were most prominent centrally, apparently because the dissipation of the heat resulted in less damage to the peripheral areas of the lung. Pulmonary megakaryocytosis was noted in seven of the experimental animals. This may have been a non-specific reaction to lung trauma.