Laparoscopic management of obturator hernia in the setting of intestinal obstruction: A report of two cases and review of literature.

Owing to its rarity and non-specific clinical features, a diagnosis of obturator hernia is often delayed until the patient presents with intestinal obstruction. Often the diagnosis is made on a Computed Tomography (CT) scan or during exploratory laparotomy. While a laparoscopic approach is well described in an elective scenario, open surgery through a midline laparotomy has been the preferred approach for obturator hernia with intestinal obstruction. However, a few cases of obstructed obturator hernia have been reported that have been managed laparoscopically. We present our experience of two elderly patients who presented with intestinal obstruction. A CT scan helped clinch the diagnosis of obturator hernia as the cause and both were managed laparoscopically.

Spontaneous cutaneous endometriosis in Mons Pubis: review of literature.

Cutaneous endometriosis is not a very often seen condition and is broadly classified as primary (spontaneous) and secondary. While perineal endometriosis arising in a previous scar has been reported, spontaneous cutaneous endometriosis in perineum is extremely rare and only three cases occurring in mons pubis have been reported in literature. We report a case of 34-year-old lady presented with a swelling in pubic region and associated dull aching pain of 1-year duration with no history of cyclical variation of symptoms. Investigations finally concluded a diagnosis of endometriosis and a Complete excision with clear margins. Clinicians should be aware that a spontaneous endometriosis in the perineum can occur and can have atypical presentation with no increase in size or pain during menstruation.

Thrombectomy in large vessel occlusion stroke-Does age matter?

OBJECTIVES: Endovascular treatment (EVT) is the gold standard treatment for emergent large vessel occlusion (LVO). The benefit of EVT for emergent LVO in elderly patients (>80 years old) is still debated as they have been under-represented in randomized controlled trials. Elderly patients with an emergent LVO are a growing population warranting further study. MATERIALS & METHODS: We included 225 consecutive patients treated with EVT for LVO either in the anterior or posterior circulation. The clinical outcome was assessed using the National Institute of Health Stroke Scale (NIHSS). Long-term functional outcome was assessed using 90-day modified ranking scale (mRS). RESULTS: Neurological improvement: A five-year higher age predicted a 0.43 higher mean NIHSS score after EVT (p = .027). After adjusting for confounders (influencing variables), the association between age and post-interventional NIHSS was reduced and non-significant (p = .17). At discharge, a five-year higher age predicted a 0.74 higher mean NIHSS (p = .003). After adjusting for confounders this association was reduced and non-significant (p = .06). Long-term functional outcome: A five-year higher age predicted a 0.20 higher mRS at three months (p < .001). When adjusting for confounders this number was reduced to 0.16, yet still highly significant (p < .001). CONCLUSIONS: Age seems to have a minor role in predicting neurological improvement after EVT but has an impact on long-term functional outcome. The decision to perform or withhold EVT should therefore not solely be based on age.

Endovascular thrombectomy at low-volume centres: A Bayesian solution.

PURPOSE: Endovascular treatment (EVT) is traditionally performed by neurointerventional radiologists at tertiary medical centres imposing long transport ways to large vessel occlusion (LVO) stroke patients in rural areas. The purpose of this study is to evaluate the technical and clinical results over time at Stavanger University Hospital, a hospital without neurointerventional expertise, where trained general interventional radiologist performs EVT. METHODS: All patients with LVO stroke treated with EVT from May 2009 to December 2018 were included in the analysis. Technical outcome was measured by the modified treatment in cerebral ischaemia (mTICI) score, functional outcome by the modified Rankin Scale (mRS), complications registered. RESULTS: A total of 235 patients were treated with EVT. An angiographically good result (mTICI 2b or 3) could be seen in 66.7% of the patients treated the first year. In 2011, the year EVT with stent retrievers was introduced, the recanalization rate rose to 81.8%, and from 2014 onwards, it was stable around 80%. After introduction of aspiration together with stent retrievers in 2012, a good functional outcome (mRS 0-2) was obtained in >40% of the treated patients. In 2018, 61.1% of the patients got a good functional outcome. CONCLUSIONS: Endovascular treatment of LVO stroke performed by general vascular interventional radiologist in close collaboration with diagnostic neuroradiologists and stroke neurologists can achieve technical revascularization results and clinical patient outcomes in line with international recommendations, and the randomized controlled studies performed. This approach may help to introduce EVT in geographical areas where this service is lacking due to the absence of neurointerventional specialists.

Endovascular Thrombectomy in the Elderly: Do Radiological and Clinical Outcomes Differ from Those in Younger Patients? A Prospective Single-Center Experience.

OBJECTIVES: Endovascular treatment (EVT) has emerged as the gold standard therapy for stroke due to large vessel occlusion (LVO). There is however limited evidence to suggest that similar efficacy can be expected in elderly patients. We aimed to assess the efficacy and safety of EVT in elderly patients (aged > 80), comparing outcomes to younger patients (aged < 80). MATERIAL AND METHODS: A total of 195 patients with LVO stroke treated with EVT were included and dichotomized by age. We compared neurological improvement, clinical 90 day outcome, technical recanalization rates, procedure-related complications, and mortality in between the groups. RESULTS: Both groups showed equally marked neurological improvement. A favorable outcome modified Rankin Scale (mRS < 2) was seen in 28% of the elderly patients compared to 46% of the younger patients (p = 0.01). mRS 0-3 was seen in 46% of the elderly patients and 58% of the younger patients (p = 0.09). The rates of successful technical recanalization did not differ between the groups and there were no differences in procedural complication rates or incidence of symptomatic intracranial bleeding. Three-month mortality rates were however higher in the elderly group. CONCLUSIONS: EVT in the elderly resulted in equally notable neurological improvement as compared to younger patients. Although the elderly had a higher mortality rate and fewer favorable clinical outcomes at 3 month follow-up, a strict upper age limit for EVT seems unjustified.

Stereotactic radiosurgery for vestibular schwannomas: a survey of current practice patterns of neurotologists.

OBJECTIVE: To evaluate the use of radiation by neurotologists practicing in the United States as a treatment modality for vestibular schwannomas (VSs). STUDY DESIGN: Cross-sectional survey. METHODS: We surveyed 302 members of the American Neurotology Society to assess the number of VS seen, the frequency with which radiation is used as a treatment modality, radiation training and experience, the impact of tumor size and patient age on treatment decisions, and radiation dose ultimately used by neurotologists. RESULTS: Responses were received from 43% (132/302) of surveyed neurotologists; of the respondents, 42% (54/132) perform stereotactic radiation. Approximately 58% (30/54) of those use gamma knife, and 44% (24/54) use Cyberknife; 36.7% of VS patients seen by neurotologists received radiation. On average, 6 additional neurotologists per year begin treating VS with stereotactic radiation. Academic and private neurotologists showed significant differences (p < 0.05) between new VS patients per year, years in practice, and maximum tumor size recommended for radiation. The most common barrier to using radiation was prevention by a neurosurgical or radiation oncology service. Neurotologists use radiation to treat other cranial base tumors as well, most commonly glomus tumors or meningiomas, and 64% of respondents irradiate neurofibromatosis Type 2. Total radiation dose and fractionation were variable. CONCLUSION: Neurotologists are increasingly choosing to treat VS with stereotactic radiation. There seem to be significant differences between academic and private neurotologists' practice characteristics. Not all neurotologists strictly adhere to the consensus statement by the International RadioSurgery Association with regard to radiation dosing and tumor size limits.

Elevated plasma total homocysteine in preeclampsia.

OBJECTIVES: To investigate the possible association between hyperhomocysteinemia and preeclampsia. METHODS: A case-control study was carried out in the Departments of Obstetrics and Gynecology of the Ghaem Hospitals in Mashhad University of Medical Sciences, Mashhad, Iran from May 2004 to August 2006 and included 75 preeclamptic patients, 37 women with mild preeclampsia, and 38 women with severe preeclampsia, in addition we included 40 controls without pregnancy complications. Plasma total homocysteine was determined in all subjects by enzyme linked immunosorbent assay. RESULTS: The 3 groups were similar in age and body. Patients with severe preeclampsia had significantly higher mean plasma levels (13.8+/-7 mg/l) than normal pregnant women (8.8+/-2.8 mg/l) and mild pre-eclamptic women (10.4+/-2.3 mg/l) (p<0.05). CONCLUSION: Women who developed severe preeclampsia have higher plasma homocysteine levels than women who remain normotensive throughout pregnancy.

Prevalence and mode of spread of hepatitis B and C in rural Sindh, Pakistan.

The aim of this study was to determine the prevalence and identify risk factors associated with the spread of hepatitis B and C in the rural areas of the upper Sindh Province, Pakistan. Included in this cross-sectional survey were 873 subjects belonging to 174 families residing in Jarwar, a small town of upper Sindh. A study using a systematic random sampling method was undertaken. One questionnaire per household was filled out and blood samples collected for hepatitis B surface antigen (HBsAg), hepatitis B core antibody total (HBcAb), and hepatitis C antibody (anti-HCV). HBsAg was reactive in 44 (5%), HBcAb in 494 (56.6%) and anti-HCV in 294 (33.7%). In the case control study, independent risk factors for exposure to hepatitis B were male sex, age greater than 16 years, absence of vaccination, previous history of jaundice, and family history of liver disease (adjusted odds ratios 1.4, 2.1, 1.7, 1.8 and 1.8, respectively). Independent risk factors for hepatitis C were age greater than 16 years, previous dental procedures, history of liver disease, lack of vaccination, and 10 or more injections in a year (adjusted odds ratios 3.7, 2.1, 2.4, 1.8 and 2.9, respectively). There was indication of intrafamilial and household clustering: for hepatitis C, parent to child p = 0.001, sibling-to-sibling p = 0.046; for hepatitis B, spouse-to-spouse p = 0.052 and parent to child p = 0.001. In conclusion, there is high exposure to hepatitis B and C in upper Sindh. There is a need to educate people about hepatitis B vaccination and iatrogenic factors responsible for transmission. The study suggests the possibility of intrafamilial spread of these viruses.

Reverse second dorsal metacarpal artery flap for reconstruction of fourth-degree burn wounds of the hand.

We sought to show how severe soft-tissue injuries of the proximal index finger caused by fourth-degree electrical burns to the hand may be surgically reconstructed. Soft-tissue coverage was provided with a reverse second dorsal metacarpal artery flap in two patients. Both digits were successfully salvaged by use of this reconstructive method. Both donor sites were closed primarily and healed without difficulty. The reverse second dorsal metacarpal artery flap provides well-vascularized tissue without excess bulk and allows near-normal hand function.

Role of connective tissue growth factor in breast implant elastomer capsular formation.

Transforming growth factor-beta (TGF-beta) has been demonstrated to be a mediator in scar formation and in multiple fibrotic disorders such as in Dupuytren contractures and in pulmonary fibrosis. Recently, it has been demonstrated that connective tissue growth factor (CTGF) is a downstream mediator of TGF-beta and acts to stimulate wound contraction and fibrosis. The purpose of this study is to assess the role of CTGF in the development of breast implant elastomer capsule formation over time and to evaluate the effects of TGF-beta and CTGF antisense (AS) oligonucleotides on capsule formation. Fifteen Sprague-Dawley rats were randomly assigned to treatment (n = 12) and control (n = 3) groups. Four 2- x 2-cm pockets were created on the dorsum deep to the panniculus carnosus in each rat. A 1- x 1-cm smooth breast implant elastomer was placed. Each rat in the treatment group received 1 ml vehicle, AS-TGF-beta, AS-CTGF, or scramble antisense oligonucleotide (AS-scramble). Control rats received either 1 ml vehicle or 1 ml saline in each pocket. At weeks 1, 3, and 5, four treatment rats and one control rat were randomly selected and killed. Tissue blocks were harvested for determination of CTGF levels using the enzyme-linked immunosorbent assay technique and for hematoxylin and eosin slides to evaluate capsule formation. Levels of CTGF in capsular tissue treated with vehicle or AS-scrambled were similar and progressively increased in tissues on weeks 1, 3, and 5, compared with normal skin. At weeks 1 and 3 after surgery, levels of CTGF were suppressed in capsules treated with AS-CTGF or AS-TGF-beta compared with normal skin and with tissues treated with vehicle or AS-scramble (p = 0.002). At week 5, levels of CTGF were similar to levels in normal skin. Histological analysis revealed reduced capsular formation in samples treated with AS-CTGF or AS-TGF-beta compared with the two other treated sites. In conclusion, a single and local treatment with AS-CTGF or AS-TGF-beta at the time of surgery reduced CTGF levels in tissue and correlated with reduced capsular formation in a rat model. These data suggest a new therapeutic strategy to reduce early capsular formation based on local application of antisense oligonucleotides targeting CTFG and TGF-beta.

Evaluation and treatment of velopharyngeal insufficiency: the University of Florida experience.

This retrospective study spans the years 1988 to 2000 and looks specifically at the treatment procedures and outcomes for the correction of velopharyngeal insufficiency (VPI). Ninety-eight patients underwent preoperative assessment by speech pathologists that included perceptual speech evaluation, videofluoroscopy, and, for some, nasendoscopy. Based on this evaluation protocol, a specific surgical procedure was chosen to serve the patients' needs. The four procedures of choice were the palatal pushback with a pharyngeal flap lining, sphincter pharyngoplasty, a superiorly based obturating pharyngeal flap, and Furlow palatoplasty. The criteria for selecting these procedures are reviewed. The results revealed VPI resolution and the establishment of normal nonnasal speech in more than 95% of the 75 patients for whom outcomes were determined. This study reiterates the importance of thorough preoperative evaluation and the individualization of the secondary corrective procedure.

gamma-Glutamyl transpeptidase in the yeast Saccharomyces cerevisiae and its role in the vacuolar transport and metabolism of glutathione.

In the yeast Saccharomyces cerevisiae, the enzyme gamma-glutamyl transpeptidase (gamma-GT; EC 2.3.2.2) is a glycoprotein that is bound to the vacuolar membrane. The kinetic parameters of GSH transport into isolated vacuoles were measured using intact vacuoles isolated from the wild-type yeast strain Sigma 1278b, under conditions of gamma-GT synthesis (nitrogen starvation) and repression (growth in the presence of ammonium ions). Vacuoles devoid of gamma-GT displayed a K(m) (app) of 18+/-2 mM and a V(max) (app) of 48.5+/-5 nmol of GSH/min per mg of protein. Vacuoles containing gamma-GT displayed practically the same K(m), but a higher V(max) (app) (150+/-12 nmol of GSH/min per mg of protein). Vacuoles prepared from a disruptant lacking gamma-GT showed no increase in V(max) (app) with nitrogen starvation. From a comparison of the transport data obtained for vacuoles isolated from various reference and mutant strains, it appears that the yeast cadmium factor 1 (YCF1) transport system accounts for approx. 70% of the GSH transport capacity of the vacuoles, the remaining 30% being due to a vacuolar (H(+)) ATPase-coupled system. The V(max) (app)-increasing effect of gamma-GT concerns only the YCF1 system. gamma-GT in the vacuolar membrane activates the Ycf1p transporter, either directly or indirectly. Moreover, GSH accumulating in the vacuolar space may exert a feedback effect on its own entry. Excretion of glutamate from radiolabelled GSH in isolated vacuoles containing gamma-GT was also measured. It is proposed that gamma-GT and a L-Cys-Gly dipeptidase catalyse the complete hydrolysis of GSH stored in the central vacuole of the yeast cell, prior to release of its constitutive amino acids L-glutamate, L-cysteine and glycine into the cytoplasm. Yeast appears to be a useful model for studying gamma-GT physiology and GSH metabolism.

Efficient in vivo catheter-based pericardial gene transfer mediated by adenoviral vectors.

Adenoviral vectors are promising agents for a number of in vivo gene therapy applications including diseases of the heart and coronary vessels. Efficient intravascular gene transfer to specific sites has been achieved in occluded vessels, but otherwise is hampered by the effect of blood flow on localized vector uptake in the vessel wall. An alternative delivery approach to coronary arteries is the expression of diffusible gene products into the pericardial space surrounding the heart and coronary arteries. However, in vivo pericardial access is comparatively difficult and has been limited to surgical approaches. We hypothesized that efficient adenovirus-mediated gene expression in pericardial lining mesothelium could be achieved by transmyocardial vector delivery to the pericardium. To evaluate this concept, a hollow, helical-tipped penetrating catheter was used to deliver vector-containing fluid directly into the intrapericardial space. The catheter was introduced percutaneously in anesthetized mongrel dogs, advanced into the right ventricle, and the tip passed through the apical right ventricular myocardium under direct radiographic visualization until the open end of the catheter tip resided in the intrapericardial space. Adenoviral vectors expressing either nuclear-localizing beta-galactosidase, cytoplasmic luciferase, or secreted human alpha 1AT reporters (Av1nBg, Av1Lu, or Av1Aa, respectively) were instilled through the catheter into the intrapericardial space. Three days later the animals were sacrificed and reporter gene expression was evaluated in pericardium, epicardium, and multiple other tissues. In animals receiving Av1nBg, beta-galactosidase activity was evident in most of the pericardial lining endothelium, up to 100% in many areas. In animals receiving Av1Lu, luciferase reporter activity was abundant in pericardial tissues, but near-background levels were observed in other organs. In animals receiving Av1Aa, human alpha 1AT was abundant (16-29 mg/ml) in pericardial fluid, but was undetectable in serum. All animals tolerated the procedure well with no electrocardiographic changes and no clinical sequelae. These observations demonstrate highly efficient adenovirus vector delivery and gene transfer and expression in the pericardium and support the feasibility of localized gene therapy via catheter-based pericardial approaches. We suggest that the pericardial sac may serve as a sustained-release protein delivery system for the generation of desired gene products or their metabolites for diffusion into the epicardial region.

Increased Intramural Retention After Local Delivery of Molecules with Increased Binding Properties: Implications for Regional Delivery of Pharmacologic Agents.

BACKGROUND: Catheter-based local vascular delivery results in concentrated qualtities of pharmaceutical agents or genes into focal areas of the arterial wall. However, intramural retention is short and has reduced the potential efficacy of this approach. It was postulated that agents that possess increased intramural binding would show increased intramural retention. Platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF) were models of agents with increased cellular and extracellular matrix binding properties. METHODS AND RESULTS: The delivery efficiency and intramural retention of 2 mL of saline containing I(125) labeled PDGF (n = 35 arteries) and bFGF (n = 24) were compared with albumin (n = 21) after local delivery into porcine coronary arteries. Animals were sacrificed at three or more prespecified timepoints: immediately after delivery, 1 day, or 3 days after delivery and if necessary at 5 or 7 days to document prolonged retention. Autoradiograms of the arterial sections were evaluated for the extent of delivery. Delivery efficiency, defined as the amount leaving the catheter and retrieved from the arterial wall, was 0.60% +/- 0.42% for albumin, 1.98% +/- 0.88% for PDGF (P =.001), and 0.31% +/- 0.11% for bFGF. The calculated intramural half-life of albumin was 7.4 hours, 56.2 hours for PDGF, and 14.9 hours for bFGF (P =.0001 for PDGF). Infusate covering >50% of the medial area was observed in 85% of arteries immediately after delivery. Although myocardial delivery was similar for albumin, PDGF, and bFGF, myocardial retention was significantlylonger for bFGF (P <.001). CONCLUSIONS: Molecules that exhibit preferential intramural binding show a longer intramural residence duration than solutes without such binding properties. In addition, delivery and subsequent prolonged retention in the myocardium can be obtained by local delivery via the arterial lumen of solutions with preferential binding properties.

[Contribution of immunofixation and laser nephelometry in the diagnosis of monoclonal immunoglobulinopathy]. / Apport de l'immunofixation et de la néphélémétrie-laser dans le diagnostic des immunoglobulinopathies monoclonales.

Immunological diagnosis of principal's monoclonal gammapathies [Waldenström's macroglobulinemia and multiple myeloma], used classically electrophoresis and immunoelectrophoresis analysis (AIE) for detection of monoclonal components. Although its specificity and sensibility, the last method stays a long analysis with critical interpreting from time to time. The present study reports results obtained with 100 sera from subjects with these diseases when using immunofixation and nephelometry-laser witch tests amounts of IgG, IgA and IgM and kappa/lambda--ratio both methods together, which are simpler and more faster than AIE.

Activation of MAP kinase in vivo follows balloon overstretch injury of porcine coronary and carotid arteries.

Vascular restenosis involves contraction, proliferation, and remodeling of the arterial wall in response to overstretch injury. Mitogen-activated protein kinases (MAPKs) are implicated in both contraction and proliferation of vascular smooth muscle (VSM), and studies of porcine carotid arterial muscle strips have shown that mechanical stretch leads to the activation of the extracellular signal-regulated kinase (ERK) family of MAPKs in vivo. We, therefore, analyzed the acute effect of mechanical overstretch injury on ERK-MAPK (herein referred to simply as MAPK) activity in porcine coronary and carotid arteries in vivo. Balloon angioplasty catheters were inflated to 6 atm three times over 5 minutes at a balloon-artery ratio of 1.2:1 in either porcine coronary or carotid arteries. The arteries were snap-frozen after angioplasty, and MAPK activity was measured. Angioplasty of the left anterior descending (LAD, n = 5), left circumflex (LCx, n = 5), and carotid (n = 5) arteries effected an increase in MAPK activity compared with the activity in uninstrumented right coronary arteries (RCAs) or carotid arteries from the same animals used for controls. Balloon angioplasty of carotid arteries led to an increase in MAPK activity that was 7.7-fold over the activity in control arteries and comparable to the activity in stretched carotid arterial muscle strips in vivo. The increase in coronary artery kinase activity on angioplasty was variable from animal to animal. The increase in MAPK activity over that in control arteries ranged from 4.5- to 31.7-fold (mean +/- SEM, 10.7 +/- 5.3) in the LAD and 1.8- to 31.3-fold (mean +/- SEM, 9.7 +/- 5.7) in the LCx. There were no apparent inherent differences in the levels of MAPK activity in the three different types of coronary arteries (RCA, LAD, and LCx) without instrumentation. MAPK activation occurs rapidly during angioplasty, suggesting that this kinase may play an early role in initiating the injury response in both porcine coronary and carotid arteries. MAPKs may be key enzymes targeted to treat or prevent restenosis.

Microparticle deposition in periarterial microvasculature and intramural dissections after porous balloon delivery into atherosclerotic vessels: quantitation and localization by confocal scanning laser microscopy.

Local delivery of pharmacologic or genetic agents with a porous balloon catheter offers a potential therapeutic approach to reducing restenosis and atherosclerosis and minimizing undesirable systemic toxicity. However, the delivery efficiency and intramural retention of liquid agents is low. The local intramural delivery and prolonged retention of 5 microns microparticles (MP) has been described previously. The current study was designed to evaluate the distribution of locally delivered MPs and to determine the effects of MP size and infusion pressure on intramural delivery efficiency. A 1% suspension of fluorescent, latex MPs (1 or 4.5 microns in diameter) was infused at either 3 or 6 atm into atherosclerotic rabbit femoral arteries (n = 32) immediately after angioplasty. Four groups of arteries were evaluated: 1) 1 micron MPs infused at 3 atm; 2) 1 micron MPs at 6 atm; 3) 4.5 microns MPs at 3 atm; and 4) 4.5 microns MP at 6 atm. The location of MPs was evaluated by fluorescent and light microscopy and confocal laser scanning microscopy. The tissue was dissolved and the delivered MPs quantified. All groups manifested numerous MPs within the vasa vasorum and periadventitial microvasculature, with a substantially lesser number within the neointimal and medial layers. The intramural deposition of the MPs was associated with dissection within the intima or media caused by the antecedent angioplasty or local delivery, indicating that an intact vessel wall is an anatomic barrier to MP delivery. The median values of fractional intramural delivery, defined as the percentage of infused MPs retained within the arterial wall, were 0.059%, 0.071%, 0.047%, and 0.062% for the groups 1 through 4, respectively (p not significant [NS]). The values of intramural particle concentration, expressed as the total number of MPs per weight of arterial tissue, were 55, 65, 1.5, and 1.2 x 10(4) MPs/mg for groups 1 through 4, respectively (p < 0.001 for 1 micron vs 4.5 microns MPs). Although more 1 microM MPs were delivered than 4.5 microns MPs, the fractional intramural delivery was unaffected by particle size or infusion pressure. The local delivery of MPs at atherosclerotic sites after angioplasty is characterized by fractional intramural delivery values similar to values of nonparticulate agents, with few MPs deposited into intima or media in the absence of a dissection caused by the antecedent angioplasty or the delivery procedure itself.