Laparoscopy in the evaluation and treatment of patients with AIDS and acute abdominal complaints

BACKGROUND

The evaluation of AIDS patients with acute abdominal complaints (AAC) is quite difficult, and surgical intervention is associated with a high complication rate. The intent of this study is to evaluate the application of laparoscopy in the diagnosis and treatment of AIDS patients with AAC.

METHODS

This is a retrospective analysis of 10 consecutive AIDS patients who presented with AAC. Each had evaluation by a surgical team with subsequent laparoscopic intervention. The charts were reviewed for age, sex, time with AIDS, AIDS comorbidities, evaluation modalities, findings, treatment modalities, and outcome.

RESULTS

Laparoscopy resulted in the successful surgical treatment of four patients, diagnosis of medically treatable conditions in four patients, and alteration of the incision site in the remaining two patients. Each patient thus received direct benefit from laparoscopy. Two complications, in the converted patients, and no mortalities were encountered.

CONCLUSIONS

Laparoscopy is a safe and effective interventional modality in the diagnosis and treatment of AAC in the AIDS patient.

Natural Infection of Eggplant by Puccinia substriata var. indica in the United States

Eggplant (Solanum melongena) and other Solanum spp. are aecial hosts for Puccinia substriata var. indica, the rust pathogen of pearl millet (Pennisetum glaucum) (2). Although long suspected to be important in epidemic initiation (1), natural infection of eggplant has never been documented in the United States. All previous observations have been the result of deliberate inoculations. Eggplant (cv. Santana) seedlings with sporulating aecia were identified in the inventory of a vegetable transplant producer near Ty Ty, GA, on 22 April 1997. Flats of seedlings were being grown in a greenhouse with adjustable sides for creating an open-air environment for temperature control. Disease incidence was approximately 1.5% in the lot of 10,000 seedlings. Lesions were found most frequently on the first true leaf or less frequently on cotyledons. Aeciospores from 15 arbitrarily selected leaves were used to inoculate pearl millet seedlings in the greenhouse. Each leaf was used to inoculate pearl millet cultivars with no known resistance, and with the Rr₁ resistance gene. Infection was obtained on all cultivars with no resistance genes, verifying pathogen identification. Fourteen isolates infected pearl millet with Rr₁, revealing that virulence to Rr₁ was common in this sample. The nearest point source of exposed pearl millet debris that could serve as a source of basidiospores was located approximately 9.7 km away from the eggplant. References: (1) H. D. Wells. Plant Dis. Rep. 62:469, 1978. (2) J. P. Wilson et al. Plant Dis. 80:806, 1996.

Effects of Temperature and Light on Germination of Urediniospores of the Pearl Millet Rust Pathogen, Puccinia substriata var. indica

Germination of urediniospores of Puccinia substriata var. indica was evaluated after 2, 4, 6, and 8 h of incubation in petri dishes containing 2% water agar under 10, 16, 20, 25, 30, and 35°C in light (1650 lux, cool white fluorescent), dark, alternate light-dark, and alternate dark-light. Less than 1% germination occurred at 35°C. At 30°C, percent germination did not significantly change after 4 h. At 10°C, percent germination increased with longer incubation. Under all illumination conditions, percent maximum germination after 4 to 8 h occurred at 20-25°C. Response surface analysis indicated that under all four illumination regimes, urediniospore germination greater than 90% occurs between 19 and 22°C after 6-7 h of incubation. Two hours of continuous light appeared to significantly delay germination, but exposure to light during the first hour of incubation was stimulatory when followed by 1 h dark.

500 total extraperitoneal approach laparoscopic herniorrhaphies: a single-institution review

At Georgia Baptist Medical Center, a community-based, university-affiliated hospital, we adopted the total extraperitoneal approach (TEPA) to laparoscopic herniorrhaphy due to potential complications in entering the abdominal cavity reported previously with the transabdominal preperitoneal technique (Am Surg 1996;62:69-72). We have also employed regional anesthesia (epidural) in 108 patients in whom the TEPA was utilized. In our institution, the TEPA has compared favorably to the transabdominal preperitoneal technique, with lower complication and recurrence rates. In patients with previous lower abdominal surgery, the TEPA is considered a relative contraindication due to the increased risk of complications (Am Surg 1997, in press). Since June 1993, we have performed 503 laparoscopic herniorrhaphies using the TEPA, with encouraging early results. To date, two recurrences have been reported, one with previous lower abdominal surgery and another whose recurrence was noted to be secondary to incomplete reapproximation of the mesh with staples around the cord structures. Four major complications include two bowel perforations and two cystotomies noted during balloon dissection of the preperitoneal space. Three of these patients had previous lower abdominal surgery. Epidural anesthesia was used in 108 patients, 4 of whom required conversion to general anesthesia due to peritoneal tears and pain associated with pneumoperitoneum. All four of these patients had previous lower abdominal surgery. In summary, the TEPA remains a viable technique for laparoscopic herniorrhaphy with acceptable complication and recurrence rates. Epidural anesthesia is well tolerated by the patients undergoing this particular repair. We feel that lower abdominal surgery may be a mitigating factor in selection of the TEPA. Continued re-evaluation of the procedure is warranted before definitive conclusions can be made.

Yield, composition, and in vitro digestibility of temperate and tropical corn hybrids grown as silage crops planted in summer

Following the harvest of corn silage crops that were planted in spring, second crops of one temperate and four tropical corn hybrids were planted under conditions of minimum tilling in four replications on August 3, 1992 and harvested on October 11, 1992 (yr 1). During the 2nd yr, second crops were planted on July 21, 1993 and harvested on October 19, 1993. Dry matter yields of the hybrids ranked similarly for both years but differed among hybrids, ranging from 7800 to 11,430 kg/ha (yr 1) and from 8470 to 13,150 kg/ha (yr 2). The temperate hybrid yielded 20% (yr 1) and 26% (yr 2) less than the lowest yielding tropical hybrid. The proportion of grain in the dry matter (DM) differed across hybrids, ranging from 14.3 to 32.2% during yr 1 and from 18.0 to 32.4% during yr 2. Composition of the DM, excluding grain, also differed for the hybrids: acid detergent fiber ranged from 38.0 to 42.2% during yr 1 and 40.0 to 48.8% during yr 2; in vitro digestible DM ranged from 60.9 to 65.1% during yr 1 and from 53.0 to 64.6% during yr 2. The temperate hybrid was the highest in acid detergent fiber and the lowest in in vitro digestible DM. Lower digestibility during yr 2 was attributed to disease, which infected 24.9 to 40.4% of the foliage of tropical hybrids and 84.3% of the temperate hybrid. Whole plant DM digestibilities differed narrowly in yr 1 (68.8 to 70.4%) but differed widely in yr 2 (62.2 to 69.9%). There were important differences among yields and compositions of tropical hybrids planted in summer, but all were superior to the temperate hybrid.

Current therapy for Crigler-Najjar syndrome type 1: report of a world registry

This study represents a multicenter survey on the management of patients with Crigler-Najjar syndrome (CNS) type 1. The aim of the survey was to find guiding principles for physicians in the care of these patients. Fifty-seven patients were included. At the time of inclusion, 21 patients had received a liver transplant (37%). The average age at transplantation was 9.1 +/- 6.9 years (range, 1-23 years); the age of the patients who had not been transplanted at the time of inclusion was 6.9 +/- 6.0 years (range, 0-23 years). Brain damage had developed in 15 patients (26%). Five patients died, and 10 are alive with some degree of mental or physical handicap. In 2 patients, ages 22 and 23 years, early signs of bilirubin encephalopathy could be reversed, in 1 by prompt medical intervention followed by liver transplantation and in the other by prompt liver transplantation. Seven patients underwent transplantation with some degree of brain damage at the time of the surgery; 1 of these died after retransplantation, 2 improved neurologically, and 4 remained neurologically impaired. The age of 8 patients with and 13 without brain damage at or before transplantation was 14.3 +/- 5.9 and 5.9 +/- 5.4 years (P < .01), respectively. Therapy of CNS type 1 consists of phototherapy (12 h/d), followed by liver transplantation. Phototherapy, although initially very effective, is socially inconvenient and becomes less efficient in the older age group, thus also decreasing compliance. Currently, liver transplantation is the only effective therapy. This survey shows that, in a significant number of patients, liver transplantation is performed after some form of brain damage has already occurred. From this, one must conclude that liver transplantation should be performed at a young age, particularly in situations in which reliable administration of phototherapy cannot be guaranteed.

Stages of decompensation in combat-related posttraumatic stress disorder: a new conceptual model

This conceptual article presents a model of severe, chronic combat-related PTSD based on several years of longitudinal clinical observations of Vietnam veterans. The model describes a repeating cycle of decompensation that profoundly disrupts the veteran's life. There appear to be "stages" of decompensation that can be described clinically and may be distinct physiologically. The stages describe a wide range of functioning, from adaptive to totally dysfunctional PTSD core symptoms, as well as several other dimensions of clinical functioning, such as affect regulation, defenses, ego states, interactions with the environment, capacity for self-destruction/suicide and capacity for attachment and insight are described for each stage. Clinical and research implications are discussed.

The effect of previous lower abdominal surgery on performing the total extraperitoneal approach to laparoscopic herniorrhaphy

At Georgia Baptist Medical Center in Atlanta, GA, we adopted the total extraperitoneal approach (TEPA) to laparoscopic herniorrhaphies because of the concerns of potential early and late complications associated with entering the abdominal cavity. In our institution, the TEPA has compared favorably with the transabdominal approach, with lower complication and recurrence rates. There has been concern, however, in performing the TEPA in patients with previous lower abdominal surgery. The question has been raised that there is increased risk of complications in these patients. From June 1993 to May 1994, we performed 247 laparoscopic herniorrhaphies in 192 patients using the TEPA. Of these, 55 hernias were repaired in 45 patients with previous lower abdominal surgery. Overall retrospective results showed a slightly higher complication rate (23.1% vs 11.3%) and slightly higher recurrence rate (1.8% vs 0%) in the patients with previous surgery over those without. Although these differences are not statistically significant, it is important to keep these risks in mind when selecting the appropriate hernia repair for each patient.

Technical considerations of the different approaches to laparoscopic herniorrhaphy: an analysis of 500 cases

Between April 1991 and April 1994, 500 laparoscopic herniorrhaphies have been performed at our institution. The transabdominal preperitoneal approach was used for 290 repairs, and the total extraperitoneal approach was used for 210 repairs. Although both repairs resulted in acceptable recurrence and complication rates, we adopted the total extraperitoneal approach in June 1993, with a resulting lower recurrence rate (0.5% versus 2.1%) and lower complication rate (3.1% versus 11.1%) when compared with the transabdominal approach. In this retrospective review, four epigastric vessel injuries (1.6%) and one bowel obstruction from a port hernia (0.5%) were attributed to the lateral port placement in the transabdominal approach. There were also two visceral injuries (1.0%) from entering the abdominal cavity in the transabdominal approach. The one visceral injury (0.6%) in the total extraperitoneal approach was a result of the balloon dissection in a patient with multiple previous lower abdominal operations. Better exposure and lateral visualization of the extraperitoneal space has led to less incidence of nerve injury (0.0% versus 2.4%) and a lower recurrence rate (0.5% versus 2.1%) in the total extraperitoneal approach. The total extraperitoneal approach to laparoscopic herniorrhaphy compares favorably to the transabdominal approach in our institution. The improved results may have been due to the technical differences between these approaches.

Rotations with Coastal Bermudagrass and Fallow for Management of Meloidogyne incognita and Soilborne Fungi on Vegetable Crops

The efficacy of fallow and coastal bermudagrass (Cynodon dactylon) as a rotation crop for control of root-knot nematode (Meloidogyne incognita race 1) and soilborne fungi in okra (Hibiscus esculentus cv. Emerald), squash (Cucurbita pepo cv. Dixie Hybrid), and sweet corn (Zea mays cv. Merit) was evaluated in a 3-year field trial. Numbers of M. incognita in the soil and root-gall indices were greater on okra and squash than sweet corn and declined over the years on vegetable crops following fallow and coastal bermudagrass sod. Fusarium oxysporum and Pythium spp. were isolated most frequently from soil and dying okra plants. Numbers of colony-forming units of soilborne fungi generally declined as the number of years in sod increased, but were not affected by coastal bermudagrass sod. Yields of okra following 2-year and 3-year sod and squash following 2-year sod were greater than those following fallow. Yield of sweet corn was not different following fallow and coastal bermudagrass sod.

Prescribed medication use among troops deploying to Somalia: pharmacoepidemiologic analysis

To describe the frequency of chronic ambulatory prescriptions dispensed to troops, pharmacists analyzed records of soldiers deploying to Somalia for Operation Restore Hope. Prescriptions recorded in the Fort Drum pharmacy data base for soldiers deploying between November 24, 1992, and January 12, 1993, were compared to the roster of troops deployed. Among 3,701 deploying soldiers, 273 patients (7.4%) received 425 prescriptions. For each 1,000 troops, 114.8 prescriptions were dispensed. Of 333 presumptive diagnoses, the most common diagnostic groups were contraceptive, musculoskeletal, dermatologic, respiratory, and cardiovascular. Of 425 prescriptions, the most common therapeutic classes of medication dispensed were oral contraceptives, anti-inflammatory drugs, acne treatments, and beta-adrenergic agonists. Generically, the common prescribed substances were contraceptives, ibuprofen, pirbuterol, temazepam, piroxicam, and beclomethasone. Although women represented 6.8% of troops, women represented 31.5% of prescription recipients and received 29.4% of prescriptions. Women were 6.5 times as likely to receive a prescription as men (p < 0.0001); this relative risk was 3.4 if contraceptives were omitted from analysis (p < 0.0001). Two hospitalizations in Somalia may have been related to medication use.

The possible relationship between transient evoked otoacoustic emissions and organ of Corti irregularities in the guinea pig

Otoacoustic emissions are believed to arise from an active process associated with the outer hair cells in the mammalian organ of Corti. They have been attributed to the presence of impedance discontinuities on the basilar membrane which might be caused by hair cell irregularities. To test this hypothesis we have investigated the possible relationship between transient evoked otoacoustic emissions (TEOAEs) and anatomical integrity in the organ of Corti. Click-evoked TEOAEs have been measured from the ear canals of normal, pigmented guinea pigs using an Otodynamics ILO88 analyser. Emissions were present in 18 out of 19 animals tested and the major frequencies observed were consistently present in different measurements over periods of up to ten weeks provided recording conditions were satisfactory. The frequency spectra of the TEOAEs resembled those measured in humans but the latencies of the responses were considerably shorter. In one acute experiment, the TEOAEs were shown to be dependent on metabolic energy as they were lost rapidly following termination with an overdose of anaesthetic. In another case, evoked emissions of long duration (sustained) at about 1 kHz were obtained from both ears. All cochleae examined showed irregularities, especially patches of mainly apical outer hair cell loss of differing extents. However, there was no evidence that substantial lesions coincided consistently with the frequency regions corresponding to the major emissions. Nevertheless, it was noted that the total energy level of emissions was proportional to the total outer hair cell loss, except in one case, where the outer hair cell loss was substantial and the energy level of TEOAEs was considerably lower. Although there is no clear relationship between TEOAEs of specific frequencies and abnormalities at the corresponding cochleotopic location in the organ of Corti which could represent impedance discontinuities, the degree of irregularity may determine the overall emission level. This finding is consistent with the idea that emissions arise as a result of irregularity producing variations in the reflection coefficient.

A comparison of transabdominal preperitoneal (TAPP) and total extraperitoneal approach (TEPA) laparoscopic herniorrhaphies

There are a variety of accepted techniques for herniorrhaphy. With the advent of laparoscopic general surgery, laparoscopic transabdominal and total extraperitoneal techniques have been added to the many options for repair of the inguinal hernia. From 5/91 to 6/93 we had performed 290 transabdominal preperitoneal (TAPP) laparoscopic herniorrhaphies on 244 adult patients. Due to concerns of potential early and late complications associated with entering the abdominal cavity, we adopted the total extraperitoneal approach (TEPA) for laparoscopic herniorrhaphies in 6/93. Between 6/93 and 12/93, 118 hernias have been repaired in 95 patients using the total extraperitoneal approach. In a retrospective comparison between these two procedures, the recurrence rate is 1.7% (5/290) for TAPP herniorrhaphies and 0% (0/118) for the TEPA. The overall complication rate for TAPP herniorrhaphies was 11.1% and included thigh paresthesias (6), inferior epigastric artery injuries (4), enterotomy (1), bowel obstruction (1), bladder injury (1), and urinary retention (14). The overall complication rate for the TEPA was 3.2% and included bladder injury (1), and urinary retention (2). Mean operative time was similar between these groups (TAPP-81.2 minutes, TEPA-92.9 minutes).

1525 laparoscopic cholecystectomies without biliary injury: a single institution's experience

Laparoscopic Cholecystectomy (LC) has become the preferred treatment of gallbladder disease. The indications for LC remain unchanged from those for open cholecystectomy (OC). A total of 1525 patients underwent LC at Georgia Baptist Medical Center between December 1989 and December 1992. The procedure was completed in 1,492 patients (97.8%) and required conversion to OC in 33 patients (2.2%). Selective intraoperative cholangiography was used in 165 patients (10.8%). Overall morbidity was 4.06%, and there were four deaths not operatively related, for a 0.26% mortality rate. There have been no biliary ductal injuries. The average hospital stay was 0.82 days, with 37.4% of the patients going home as true outpatients and 44.5% going home on postop Day one. Most published series on LC report a small incidence of biliary injury. We feel that with meticulous dissection of the cystic duct and use of selective intraoperative cholangiography to define unsure anatomy, biliary injury can be minimized.

Diagnostic laparoscopy for suspected appendicitis

One hundred consecutive patients who underwent diagnostic laparoscopy for suspected appendicitis were evaluated to assess the appropriate clinical setting for laparoscopic appendectomy. The usefulness of diagnostic laparoscopy in the setting of acute abdominal pain has been well documented. However, there is debate about the use of laparoscopy for definitive therapy. The purpose of this study is to evaluate the decision making process during diagnostic laparoscopy for suspected appendicitis. When pathology is identified other than in the appendix, the majority of patients can be treated without converting to an open procedure. In patients found to have no obvious pathology, incidental appendectomy can be performed laparoscopically. When appendicitis was identified, the majority of patients could be treated safely without converting to an open technique. However, there were certain clinical situations that necessitated conversion to an open operation. Involvement of the cecum or perforation at the base of the appendix puts the appendiceal stump at risk for leak and abscess formation. Evaluation of the cecum by palpation for a mass should also be performed in this situation. Another situation in which conversion to an open technique is warranted is an appendiceal abscess with adherent small bowel. The friability of bowel wall greatly increases the risk for bowel injury in this setting. Laparoscopy is a useful technique for the diagnosis and treatment of abdominal pain even if the appendix is normal on inspection. Conversion to an open operation should be employed when inflammation or perforation occurs at the base of the appendix and when bowel is found to be adherent to an appendiceal abscess.

The historical evolution of PTSD diagnostic criteria: from Freud to DSM-IV

The present study examined the evolution of the diagnostic criteria from the early writings of Sigmund Freud to the current DSM-IV. Freud's original model of neurosis, known as Seduction Theory, was a post-traumatic paradigm which placed emphasis on external stressor events. In 1897, due to a confluence of factors, he shifted his paradigm to stress intrapsychic fantasy as the focus of analytic treatment for traumatic neurosis. Freud's thinking influenced both the DSM-I and II classification of stress response syndromes as transient reactive processes. However, it is evident from his lectures in 1917-1918 that he understood the interrelatedness of what today is the four diagnostic categories in the DSM-IV.

The medical status of methadone maintenance patients in treatment for 11-18 years

To assess the safety and potential health consequences of long-term methadone maintenance treatment, we identified 111 male patients admitted to methadone maintenance treatment between 1965 and 1968, still enrolled in 1980 and in continuous treatment for at least 10 years. We were able, between 1980 and 1985, to examine patients or review records of 110 patients (99%). Most medical diagnoses, symptomatic complaints, physical examination findings and laboratory test results occurred with similar frequency in the long-term methadone maintenance patients and in a group of 56 long-term heroin addicts. These data suggest that prolonged methadone maintenance treatment is safe and is not associated with unexpected adverse effects.

Current treatment recommendations for leishmaniasis

OBJECTIVE

To review the epidemiology, clinical presentation, risk factors for transmission, and pathogenesis of leishmaniasis, as well as current treatment options for this disease. DATA SOURCES/DATA SELECTION: We reviewed unclassified medical-threat briefing material, subject-matter reviews, and case reports from the world's infectious disease literature. We concentrated on literature pertaining to the pathogenesis and management of leishmaniasis indigenous to Southwest Asia.

DATA EXTRACTION

Data from subject reviews published in the English language were evaluated. Case reports and clinical trials provided supplemental data on evolving theories and management options.

DATA SYNTHESIS

The clinical presentation of leishmaniasis is highly variable. Management relies heavily upon the use of parenteral antimonial drugs. Although these agents are effective in most cases, toxicity and the emergence of resistance limit the usefulness of standard therapies. Alternative treatment modalities include heat, surgical curettage, ketoconazole, metronidazole, pentamidine, rifampin, amphotericin B, aminoglycosides, allopurinol, and immunotherapy.

CONCLUSIONS

Although the number of reported cases of leishmaniasis in the US has generally been low, there is a possibility that more cases may be reported in the future because of the large number of military personnel returning to this country from endemic areas. Medical personnel, particularly those working in governmental institutions, should be familiar with the pathogenesis of this unusual infection as well as potential treatment options.

An early review of 800 laparoscopic cholecystectomies at a university-affiliated community teaching hospital

Laparoscopic cholecystectomy (LC) was first performed at Georgia Baptist Medical Center (GBMC) in December 1989, subsequently becoming the treatment of choice for most patients with symptomatic gallbladder disease. Early in the authors' series, all patients evaluated for cholecystitis were treated laparoscopically, unless the third party refused reimbursement or the attending surgeon was not trained in LC. Indications for LC were no different than for standard open cholecystectomy (OC). Eight hundred patients from December 1989 to March 1991 had an attempted LC at GBMC. The procedure was completed in 782 patients (97.7%) and required conversion to OC in 18 patients, (2.3%) primarily because of technical difficulties such as dense adhesions or gangrenous changes. No patient sustained a trocar injury to the intra-abdominal viscera, bile ducts injury, or major vascular injury. Overall morbidity was 3.1 per cent and mortality 0.13 per cent. Selective cholangiography (SIOC) was used in 14 per cent. Endoscopic retrograde cholangiopancreatography (ERCP), choledochoscopy, and Fogarty catheter techniques were used for common bile duct stone management. Average hospitalization was 0.89 days, with 85 per cent discharged in less than 24 hours. Average operative time was 86 minutes (range: 25 to 353). Patients returned to full activities at home in 8.4 days. Savings on hospital charges to patients averaged $1,100 for inpatient LC and $2,500 for outpatient LC when compared to 1989 costs for OC. Laparoscopic cholecystectomy is the current surgical procedure of choice for most patients with cholecystitis and can be done at least as safely as standard open cholecystectomy. The morbidity appears to be significantly less with LC, but longer follow-up is needed to confirm these preliminary findings.(ABSTRACT TRUNCATED AT 250 WORDS)