Fox Den Disease: An Interesting Case Following Delayed Diagnosis

Pyoderma fistulans sinifica, also known as fox den disease, is a rare and poorly understood inflammatory disorder of the skin and subcutaneous tissues. This disorder is often mistaken for other inflammatory skin disorders and treated inappropriately. The authors describe the case of a 53-year-old male who presented to the colorectal surgery service with a longstanding diagnosis of perirectal Crohn's disease. Despite aggressive immunosuppression and numerous surgical procedures, the patient continued to have unrelenting purulent drainage from the skin of his buttocks. Following wide excision of the affected skin and subcutaneous tissues by the colorectal surgeon, the plastic surgery team reconstructed the 30 cm x 55 cm wound using a combination of local flaps and skin grafts. The initial pathology report of the excised specimen confirmed the presence of nonspecific abscesses and inflammation. Upon special request by the plastic surgery team, the sample was resectioned with the specific intent of establishing a diagnosis of fox den disease. The additional slides met the criteria for an unequivocal diagnosis of fox den disease. Immunosuppression was discontinued and the patient healed his wounds without complication. Fox den disease is often overlooked because of the obscurity of the disease and the special histological sectioning needed to establish a diagnosis. In this case, the patient was unnecessarily treated with immunosuppressive drugs for more than 3 decades because of a misdiagnosis. With increased awareness of fox den disease, perhaps its pathophysiology can be better elucidated as more patients are appropriately diagnosed and treated.

Zoonotic protozoa in the marine environment: a threat to aquatic mammals and public health

This collection of abstracts provides an account of four presentations at the 19th International Conference of the World Association for the Advancement of Veterinary Parasitology (WAAVP)(held in New Orleans, LA, USA from 10–14 August 2003) in a symposium session on zoonotic protozoan parasites found in the marine environment and chaired by Ronald Fayer and David Lindsay.The focus was on three genera of parasites of veterinary and public health concern—Toxoplasma,Giardia, and Cryptosporidium with emphasis on their epidemiology in the marine environment.

Are there gender-specific aspects of gastric banding? Data analysis from the quality assurance study of the surgical treatment of obesity in Germany

BACKGROUND

Since 1 January 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg.

METHODS

Data collection on the results of gastric banding procedures was started in 2005, and the data are registered in an online database. Follow-up data were collected once a year. Participation in the quality assurance study is voluntary.

RESULTS

Since 2005, 3,453 gastric banding procedures have been performed at 88 hospitals. The mean age of patients was 40.7 years, and the mean body mass index (BMI) was 45.2 kg/m2. BMI and comorbidities are significantly higher in male patients. Regarding gender-specific aspects, there are no significant differences in the perioperative complication rates. The amelioration rate of comorbidities in male patients is lower than in female patients.

CONCLUSION

Gastric banding in Germany is generally performed in patients with a BMI below 45 kg/m2. The perioperative complication rate is low. Data from the nationwide survey of the German Bariatric Surgery Registry show significant differences in preoperative comorbidities and their amelioration between male and female patients. There is a need for further evaluation of gender-specific aspects of gastric banding procedures to optimize patient selection, reduce specific postoperative complications, and achieve long-term effects on weight loss and remission of comorbidities.

Autonomic nerve regulation of colonic peristalsis in Guinea pigs

Background/Aims

Colonic peristalsis is mainly regulated via intrinsic neurons in guinea pigs. However, autonomic regulation of colonic motility is poorly understood. We explored a guinea pig model for the study of extrinsic nerve effects on the distal colon.

Methods

Guinea pigs were sacrificed, their distal colons isolated, preserving pelvic nerves (PN) and inferior mesenteric ganglia (IMG), and placed in a tissue bath. Fecal pellet propagation was conducted during PN and IMG stimulation at 10 Hz, 0.5 ms and 5 V. Distal colon was connected to a closed circuit system, and colonic motor responses were measured during PN and IMG stimulation.

Results

PN stimulation increased pellet velocity to 24.6 ± 0.7 mm/sec (n = 20), while IMG stimulation decreased it to 2.0 ± 0.2 mm/sec (n = 12), compared to controls (13.0 ± 0.7 mm/sec, P < 0.01). In closed circuit experiments, PN stimulation increased the intraluminal pressure, which was abolished by atropine (10⁻⁶ M) and hexamethonium (10⁻⁴ M). PN stimulation reduced the incidence of non-coordinated contractions induced by NG-nitro-L-arginine methyl ester (L-NAME; 10⁻⁴ M). IMG stimulation attenuated intraluminal pressure increase, which was partially reversed by alpha-2 adrenoceptor antagonist (yohimbine; 10⁻⁶ M).

Conclusions

PN and IMG input determine speed of pellet progression and peristaltic reflex of the guinea pig distal colon. The stimulatory effects of PN involve nicotinic, muscarinic and nitrergic pathways. The inhibitory effects of IMG stimulation involve alpha-2 adrenoceptors.

Revisiting the Lissajous figure as a tool to study bistable perception

During bistable vision perception spontaneously "switches" between two mutually exclusive percepts despite constant sensory input. The endogenous nature of these perceptual transitions has motivated extensive research aimed at the underlying mechanisms, since spontaneous perceptual transitions of bistable stimuli should in principle allow for a dissociation of processes related to sensory stimulation from those related to conscious perception. However, transitions from one conscious percept to another are often not instantaneous, and participants usually report a considerable amount of mixed or unclear percepts. This feature of bistable vision makes it difficult to isolate transition-related visual processes. Here, we revisited an ambiguous depth-from-motion stimulus which was first introduced to experimental psychology more than 80 years ago. This rotating Lissajous figure might prove useful in complementing other bistable stimuli, since its perceptual transitions only occur at critical stimulus configurations and are virtually instantaneous, thus facilitating the construction of a perceptually equivalent replay condition. We found that three parameters of the Lissajous figure - complexity, line width, and rotational speed - differentially modulated its perceptual dominance durations and transition probabilities, thus providing experimenters with a versatile tool to study the perceptual dynamics of bistable vision.

[Current Situation of Antibiotic Prophylaxis in Obesity and Metabolic Surgery - Data Analysis from the Study for Quality Assurance in Operative Treatment of Obesity in Germany]

BACKGROUND

Since January 2005, the situation of metabolic and obesity surgery in Germany has been constantly evaluated by the German Bariatric Surgery Registry (GBSR). Data registration is performed using an internet online database with prospective data collection. All registered data were analysed in cooperation with the Institute of Quality Assurance at the Otto-von-Guericke University Magdeburg.

METHODS

Data collection includes primary and revision/redo-procedures. A main focus of the current study is the analysis of data regarding the perioperative management, in particular, administration of antibiotics.

RESULTS

Since 2005 a significant increase of primary bariatric procedures has been reported. For evaluation of the antibiotic regimen 12 296 primary operations including 684 balloons (BIB), 2950 gastric bandings (GB), 5115 Roux-en-Y-gastric bypasses (RYGBP), 120 Scopinaro's biliopancreatic diversions (BPD), 164 duodenal switches (DS), 3125 sleeve gastrectomies (SG) and 138 other procedures were analysed. In total 77.3 % of the patients with primary procedures received perioperative antibiotics. Patients without concomitant comorbidities received antibiotics significantly less often compared to those with comorbidities. Wound infection rates were comparable for patients who underwent either gastric banding or sleeve gastrectomy.

CONCLUSION

Surgery has been accepted step by step as a treatment for morbid obesity and its comorbidities in Germany during the last few years. There is only little experience in the literature regarding antibiotic therapy as well as prophylaxis in bariatric surgery. Based on the results of the current study we recommend rather the selective than the routine use of antibiotics depending on different parameters, e.g., operative time, preoperative BMI and concomitant comorbidities.

Regional difference in colonic motility response to electrical field stimulation in Guinea pig

Background/Aims

In isolated guinea-pig colon, we investigated regional differences in peristalsis evoked by intrinsic electrical nerve stimulation.

Methods

Four colonic segments from mid and distal colon of Hartley guinea pigs, were mounted horizontally in an organ bath. Measurement of pellet propulsion time, intraluminal pressure, electrical field stimulation (EFS; 0.5 ms, 60 V, 10 Hz), and response of pharmacological antagonists, were performed to isolated segments of colon to determine the mechanisms underlying peristaltic reflexes evoked by focal electrical nerve stimuli.

Results

In fecal pellet propulsion study, the velocity of pellet propulsion was significantly faster in the distal colon and decreased gradually to the proximal part of the mid colon. Intraluminal pressure recording studies showed that luminal infusion initiated normal peristaltic contractions (PCs) in 82% trials of the distal colon, compared to that of mid colon. In response to EFS, the incidence of PCs was significantly increased in the distal colon in contrast, the incidence of non-peristaltic contractions (NPCs) was significantly higher in the middle-mid colon, distal-mid colon and distal colon, compared to that of proximal-mid colon. Addition of L-NAME into the bath increased the frequency of NPCs. EFS failed to cause any PCs or NPCs contractions in the presence of hexamethonium, atropine or tetrodotoxin.

Conclusions

This study has revealed that electrical nerve stimulation of distal colon is the most likely region to elicit a peristaltic wave, compared with the mid or proximal colon. Our findings suggest that EFS-evoked PCs can be modulated by endogenous nitric oxide.

Clinical and MRI results after microfracture of osteochondral lesions of the talus

PURPOSE

Arthroscopic microfracture (AM) of osteochondral lesions of the talus is used to induce intrinsic refilling of the defect and reduce pain. The aim of this retrospective study was to investigate the clinical state after AM and the MRI outcome.

METHODS

A total of 22 patients [10 women, 12 men, 31 years old (mean, 13-68 range)] treated for osteochondral lesions of the talus by AM were examined 2 years (median) postoperatively and pre- and postoperative MRI results compared. Swelling/effusion, articular constriction, joint pain, and range of motion restriction were documented. Clinical state was evaluated using the AOFAS hindfoot score. MRI was used to assess the size of the defect, presence of bone marrow edema, cysts and effusion, thickness of repair tissue, and integrity of the cartilage.

RESULTS

In all but six cases, the defect was located at the medial shoulder of the talus. The postoperative AOFAS score at follow-up was 87.5 points (median 36-100 points range). Seven patients were free of pain, 11 had "mild, occasional" pain, 1 "moderate daily", and 3 "severe, almost always present" pain (AOFAS). The defect volume was significantly reduced from 377 mm(3) preoperatively (median, interquartile distance: 417 mm(3)) to 249 mm(3) postoperatively (median, IQD: 336 mm(3), p = 0.019, Wilcoxon). In 7 cases, the defect was completely filled, in 11 partially and in 4 only slightly.

CONCLUSION

After AM of osteochondral lesions of the talus, 18 of 22 patients had no or mild, occasional pain at 2 years follow-up. On MRI, the lesion volume had been reduced and filling with repair tissue was found.

Are there gender-specific aspects of sleeve gastrectomy-data analysis from the quality assurance study of surgical treatment of obesity in Germany

Since 1 January 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. Data are registered in an internet online database. Data collection on the results of sleeve gastrectomy was started in 2006. Follow-up data were collected once a year. Participation in the quality assurance study is voluntary. Since 2005, 3,125 sleeve gastrectomies have been performed in 80 hospitals. The number of procedures has increased from 1 in 2005 to 1,564 in 2010. Initially, the leakage rate was 7 % in 2007. The leakage rate dropped to 1.7 in 2010. The mean age of patients was 43.5 years and mean body mass index (BMI) was 52.03 kg/m(2). BMI and comorbidities are significantly higher in male than in female patients. The leakage rate in female patients was, at 1.60 %, significantly lower than in male patients, at 3.28 %. Sleeve gastrectomy is becoming more and more popular in Germany. But the postoperative complication rate is still high. Data from the nationwide survey of bariatric surgery in Germany show significant differences in preoperative comorbidities and complication rates between male and female patients. There is a need for further evaluation of gender-specific aspects to optimize patient selection and reduce specific postoperative complications.

Radiograph-based study of gender-specific vertebral area gain in healthy children and adolescents as a function of age, height, and weight

This study reports gender-specific vertebral area gain data from children and adolescents. Vertebral area was measured on lateral and anteroposterior thoracic and lumbar spine radiographs from 100 female and 100 male subjects aged 7-28 yr. T9, T11, T12, L1, and L2 X-ray area calculation was based on calculation of the area of the geometric figure of a trapezoid whose 2 nonparallel sides were equal in length, taking account of the waisted shape of the vertebrae. Both the boys and girls of our study population showed statistically significant dependence (p<0.001) of vertebral area gain on chronologic age, height, and weight right through the end of puberty, and especially so up to age 15 yr. However, height and weight were clearly better predictors of lateral and anteroposterior vertebral area gain than was chronologic age. Once vertebral growth is complete by age 18 yr or so, the lateral vertebral areas of the male subjects-regardless of body weight and height-are, on average, 25% larger, and the anteroposterior areas up to 30% larger than those of their female counterparts. After adjusting for chronologic age, height, and weight however we did not find significant differences, between gender, in vertebral area of male and female subjects, neither among children younger than 11 yr nor adolescents ages of 12-14 yr and young adults older than 18 yr.

[New data on quality assurance in bariatric surgery in Germany]

BACKGROUND

Since January 1st 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg.

METHODS

The voluntary data registration occurs in an internet online data bank. All primary bariatric procedures as well as re- and redo-procedures are documented. Follow-up data were collected once a year. Participation in the quality assurance study is obligatory for certificated centres.

RESULTS

Since 2005 13,879 bariatric procedures have been performed at 83 hospitals. The number of primary procedures has increased from 596 in 2005 to 11,835 in 2010. Revisional surgery has been performed in 1,438 patients since 2005. Sleeve gastrectomy (SG) is the major procedure with 1,564 operations in 2010. The mean BMI was 48.8 kg/m². The incidence of comorbidities was 84.8%.

CONCLUSION

Bariatric surgery has become more accepted in Germany. Beside the Roux-en-Y gastric bypass, sleeve gastrectomy is the most frequently performed operation. BMI and incidence of comorbidities are still high in comparison with literature values. Due to the lack of evidence, more randomised studies are necessary to standardise operative techniques and evaluate patient selection criteria. Quality assurance studies support a detailed analysis of these parameters.

Social interaction attenuates stress responses following chronic stress in maternally separated rats

Early life stress has been implicated as a risk factor for functional gastrointestinal (GI) disorders. Hypothalamic oxytocin (OXT) is well known to regulate social interactions and affiliative behaviors. We have shown that maternal separation (MS) induces GI dysmotility and impair hypothalamic OXT expression in response to chronic homotypic stress (CHS). We studied whether social interaction can improve GI dysmotility and OXT expression in MS rats. Male neonatal SD rats were exposed to MS for 180 min from postnatal day (PND)-2 to PND-14. After weaning, 3MS rats were housed together (pure MS). In another group, 1MS rat was housed with 2 control rats (mixed MS). Anxiety-like behaviors were evaluated in elevated plus maze (EPM). Solid gastric emptying (GE) and colonic transit (CT) were measured following CHS loading. Expression of corticotropin releasing factor (CRF) and OXT in the paraventricular nucleus (PVN) were evaluated by real time RT-PCR and immunohistochemistry. Pure MS rats demonstrated increased anxiety-like behaviors, which were significantly reduced in mixed MS rats. Delayed GE (31.5±2.8%, n=6) and accelerated CT [Geometric center (GC) =8.9±0.8, n=6] observed in pure MS rats were restored in mixed MS rats (GE=67.8±3.8%, GC=6.7±1.2, n=6, P<0.05) following CHS. OXT mRNA expression was upregulated, while CRF mRNA expression was downregulated in mixed MS rats, compared to pure MS rats. The number of OXT-immunoreactive cells was significantly increased following CHS at the PVN in mixed MS rats. Our study may contribute to the treatment strategies for GI motility disorders associated with early life stress.

Anti-stress effects of transcutaneous electrical nerve stimulation (TENS) on colonic motility in rats

BACKGROUND

Disorders of colonic motility may contribute to symptoms in patients with irritable bowel syndrome (IBS), and stress is widely believed to play a major role in developing IBS. Stress increases corticotropin releasing factor (CRF) of the hypothalamus, resulting in acceleration of colonic transit in rodents. In contrast, hypothalamic oxytocin (OXT) has an anti-stress effect via inhibiting CRF expression and hypothalamic-pituitary-adrenal axis activity. Although transcutaneous electrical nerve stimulation (TENS) and acupuncture have been shown to have anti-stress effects, the mechanism of the beneficial effects remains unknown.

AIMS

We tested the hypothesis that TENS upregulates hypothalamic OXT expression resulting in reduced CRF expression and restoration of colonic dysmotility in response to chronic stress.

METHODS

Male SD rats received different types of stressors for seven consecutive days (chronic heterotypic stress). TENS was applied to the bilateral hind limbs every other day before stress loading. Another group of rats did not receive TENS treatment.

RESULTS

TENS significantly attenuated accelerated colonic transit induced by chronic heterotypic stress, which was antagonized by a central injection of an OXT antagonist. Immunohistochemical study showed that TENS increased OXT expression and decreased CRF expression at the paraventricular nucleus (PVN) following chronic heterotypic stress.

CONCLUSIONS

It is suggested that TENS upregulates hypothalamic OXT expression which acts as an anti-stressor agent and mediates restored colonic dysmotility following chronic stress. TENS may be useful to treat gastrointestinal symptoms associated with stress.

Upregulation of mucosal 5-HT3 receptors is involved in restoration of colonic transit after pelvic nerve transection

BACKGROUND

Colonic dysfunction occurs after pelvic autonomic nerve damage. The enteric nervous system can compensate. We investigated the role of mucosal serotonin receptors, 5-HT(3) and 5-HT(4) , in the colonic motility restoration over 2 weeks after parasympathetic pelvic nerve transection in a rat model.

METHODS

Male Sprague-Dawley rats underwent pelvic nerve transection or sham operation. Colonic transit was expressed as the geometric center of (51) Cr distribution. Mucosal 5-HT(3) and 5-HT(4) receptor expression was evaluated by Western blot. Intraluminal pressure increase was measured after 5-HT(3) (ondansetron) or 5-HT(4) receptor antagonist (GR125487) administration in vitro in sham and denervated distal colons.

KEY RESULTS

At 2 weeks, colonic transit in the denervated group was 30% slower compared to the sham group (P < 0.01). At 1 and 2 weeks, 5-HT(3) receptor expression was increased two-fold in the denervated group, compared to shams (P < 0.05). A three-fold smaller dose of ondansetron was required in denervated tissues to inhibit intraluminal pressure rise than in sham colons (P < 0.01). There was no difference in the expression of 5-HT(4) receptor or the response to GR125487 in denervated vs sham colons.

CONCLUSIONS & INFERENCES

Colonic motility was restored to approximately 70% normal over 1 week without further improvement at 2 weeks. Enteric nervous system compensated by upregulating mucosal 5-HT(3,) but not 5-HT(4,) receptors.