Laparoscopic Hartmann's procedure for fecal peritonitis resulting from perforation of the left-sided colon in elderly and severely ill patients

BACKGROUND

Traditional treatment for fecal peritonitis resulting from perforation of the left-sided colon has been performed using Hartmann's procedure to reduce the high mortality caused by anastomotic leakage. However, the morbidity rates associated with abdominal incision (due in great part to wound infection, and dehiscence of abdominal fascia) are high. Therefore, we propose using laparoscopic Hartmann's procedure with abdominal incisions only for the port site to reduce the high morbidity associated with the laparoscopic procedure as compared to open surgery.

METHODS

Between April 2008 and July 2011, we treated 16 consecutive patients (median age, 83 years) with fecal peritonitis resulting from perforations in the left-sided colon due to various causes. The American Society of Anesthesiologists score of each patient was either IV or V. Patients underwent a four-port laparoscopic Hartmann's procedure. Specimens were extracted through the stoma site. Irrigation of the abdominal cavity with more than 10 L of saline was performed in every case, as was insertion of three 10-mm silicon drains via the port site into the left- and right subphrenic spaces or the pouch of Douglas.

RESULTS

The median total surgical time was 166 min (range, 123-250 min). There were no intraoperative complications, and there was no need to convert to open surgery. Fourteen patients survived. There was no wound infection or dehiscence of abdominal fascia. Successful laparoscopic reversals of the laparoscopic Hartmann's procedure were performed in all 14 survivors.

CONCLUSIONS

This laparoscopic Hartmann's procedure is a promising surgical strategy for treating fecal peritonitis arising from perforation of the left-sided colon.

Impact of smear microscopy results and observed therapy on tuberculosis treatment in Mombasa, Kenya

SETTING

Tuberculosis (TB) treatment center at Coast Provincial General Hospital in Mombasa, Kenya.

OBJECTIVES

To describe TB management practices in a facility in coastal Kenya and identify factors associated with poor treatment outcomes.

DESIGN

Retrospective review of patient treatment records from January 2008 to June 2009. Treatment outcomes of patients were classified as treatment success (cure or treatment completion) or poor treatment outcome (treatment failure, death or default). Relative risk regression was used to determine the association between exposures of interest and poor treatment outcomes.

RESULTS

Records were obtained from a total of 183 patients: 142 (78%) had pulmonary TB, 68 (37%) were human immunodeficiency virus (HIV) infected and 81 (44%) had acid-fast bacilli (AFB) positive smear micros- copy. Most treated individuals (86%) achieved a successful treatment outcome as defined by the World Health Organization. Of those with poor treatment outcomes, 64% defaulted, 32% died, and 4% failed treatment. Initial negative AFB smear and HIV co-infection were associated with poor treatment outcomes (RR 3.32, 95%CI 1.22-8.99 and RR 4.61, 95%CI 1.69- 12.59, respectively).

CONCLUSION

Strategies to accelerate accurate diagnosis of smear-negative TB and increase patient retention during treatment, especially in HIV co-infected individuals, are needed to reduce poor treatment outcomes in Kenya.

Effect of κ-opioid receptor agonist on the growth of non-small cell lung cancer (NSCLC) cells

BACKGROUND

It is becoming increasingly recognised that opioids are responsible for tumour growth. However, the effects of opioids on tumour growth have been controversial.

METHODS

The effects of κ-opioid receptor (KOR) agonist on the growth of non-small cell lung cancer (NSCLC) cells were assessed by a cell proliferation assay. Western blotting was performed to ascertain the mechanism by which treatment with KOR agonist suppresses tumour growth.

RESULTS

Addition of the selective KOR agonist U50,488H to gefitinib-sensitive (HCC827) and gefitinib-resistant (H1975) NSCLC cells produced a concentration-dependent decrease in their growth. These effects were abolished by co-treatment with the selective KOR antagonist nor-BNI. Furthermore, the growth-inhibitory effect of gefitinib in HCC827 cells was further enhanced by co-treatment with U50,488H. With regard to the inhibition of tumour growth, the addition of U50, 488H to H1975 cells produced a concentration-dependent decrease in phosphorylated-glycogen synthase kinase 3β (p-GSK3β).

CONCLUSION

The present results showed that stimulation of KOR reduces the growth of gefitinib-resistant NSCLC cells through the activation of GSK3β.

Experience with rifabutin replacing rifampin in the treatment of tuberculosis

SETTING

The use of a rifamycin in anti-tuberculosis treatment regimens is crucial for shortening treatment and achieving favorable outcomes. Rifampin (RMP) is the recommended rifamycin, although adverse effects (AEs) may require its discontinuation. The use of rifabutin (RFB), a rifamycin with activity against Mycobacterium tuberculosis, in patients with an RMP-related AE has not been well studied.

OBJECTIVE

To review our experience with RFB in tuberculosis (TB) treatment.

METHODS

We included TB patients who received RFB in their treatment regimens from 2003 to 2009. We evaluated the indications for RFB and, if applicable, the likelihood that RMP caused an AE. We identified RMPrelated AEs associated with RFB intolerance.

RESULTS

One hundred subjects were included. The indications for RFB use were RMP-related AE (57%), con- current antiretroviral therapy (21%), potential/actual interaction with other medications (14%), and as part of an alternative regimen in liver disease (8%). Nineteen patients experienced an AE while taking RFB. Among patients with a prior RMP-related AE, 80% of whom were successfully treated with RFB, only a dermatologic AE was associated with subsequent RFB intolerance.

CONCLUSIONS

Our study suggests that RFB is well tolerated by patients who develop RMP-related AEs. There may be an increased risk for RFB-related AE in patients who experienced RMP-related dermatologic events.

Two-stage hepatectomy for multiple bilobar colorectal liver metastases

BACKGROUND

As surgical resection of colorectal liver metastases (CLM) remains the only treatment for cure, efforts to extend the surgical indications to include patients with multiple bilobar CLM have been made. This study evaluated the long-term outcome, safety and efficacy of two-stage hepatectomy (TSH) for CLM in a large cohort of patients.

METHODS

Patients undergoing surgery between December 1996 and December 2009 were reviewed. The early postoperative and long-term outcomes as well as the patterns of failure to complete TSH and its clinical implications were analysed.

RESULTS

Eighty patients were scheduled to undergo TSH. Sixty-one patients had completion of TSH combined with (58 patients), or without (3) portal vein embolization/ligation (PVE/PVL). Five patients were excluded after first-stage hepatectomy and 14 after PVE/PVL. The 5-year overall survival rate and median survival in patients who completed TSH were 32 per cent and 39·6 months respectively, and corresponding recurrence-free values were 11 per cent and 9·4 months respectively. Six patients were alive beyond 5 years after TSH. Multivariable logistic regression analysis showed that failure to complete TSH was driven by two independent prognostic scenarios: three or more CLM in the future remnant liver (FRL) combined with age over 70 years predicted tumour progression after first-stage hepatectomy, and three or more CLM in the FRL combined with carcinomatosis at the time of first-stage hepatectomy predicted the development of additional FRL metastases after PVE/PVL.

CONCLUSION

A therapeutic strategy using TSH provided acceptable long-term survival with no postoperative mortality. Further efforts are needed to increase the number of patients who undergo TSH successfully.

Use of prostaglandin E1 (lipo-PGEi) to treat Raynaud's phenomenon associated with connective tissue disease: thermographic and subjective assessment

Four patients with connective tissue disease who had been suffering from severe Raynaud's phenomenon were treated with an intravenous infusion of prostaglandin E1 (PGE1) and its effectiveness was assessed by thermography and a questionnaire approach. PGE1 in a lipid microsphere formulation (lipo-PGE1) produced a significantly greater increase in lesional skin temperature compared with treatment with PGE1 clathrated in α-cyclodextrin 12 months previously in the same group of patients. These results were supported by the subjective assessment obtained from the patients by questionnaire.

A study of lesions induced in Seriola dumerili infected naturally with Streptococcus dysgalactiae

An outbreak of disease in Seriola dumerili occurred from August to October in 2007 and 2008. The fish developed lesions of the caudal peduncle, pectoral and/or dorsal fin and the heart. The lesions were characterized by moderate to severe infarction with areas of microabscessation and multifocal granulomatous inflammation associated with the presence of Streptococcus dysgalactiae antigen. This is the first report to describe the immunohistology of the lesions induced in S. dumerili following natural infection with S. dysgalactiae.

Racial disparities in primary and reactivation tuberculosis in a rural community in the southeastern United States

SETTING

A rural section of a county in central Florida.

BACKGROUND

Racial disparities in tuberculosis disease (TB) are substantial in the United States.

OBJECTIVE

To determine if TB was attributable to primary infection, reactivation or both.

DESIGN

A population-based survey of latent tuberculosis infection (LTBI), a case-control analysis of TB, and a cluster analysis of TB isolates were performed between 1997 and 2001.

RESULTS

Of 447 survey participants, 135 (30%) had LTBI. Black race was strongly associated with LTBI among US-born (OR 2.6, 95%CI 1.3-5.5) and foreign-born subjects (OR 4.3, 95%CI 2.2-8.4). Risk factors for TB included human immunodeficiency virus (HIV; OR 27.4, 95%CI 10.1-74.1), drug use (OR 4.6, 95%CI 1.7-12.4) and Black race (OR 3.4, 95%CI 1.2-9.6). The population risk of TB attributable to Black race was 64%, while that attributable to HIV was 46%. Cluster analysis showed 67% of TB cases were clustered, but Blacks were not at a significantly increased risk of having a clustered isolate (OR 2.1, 95%CI 0.12-36.0).

CONCLUSION

Both reactivation TB and recent TB transmission were increased among Blacks in this community. Therefore, LTBI screening and intensive contact tracing, both followed by LTBI treatment, will be needed to reduce TB in Blacks.

Subdiaphragmatic vagotomy promotes nociceptive sensitivity of deep tissue in rats

To verify whether vagal dysfunction is associated with chronic pain, we evaluated the effects of subdiaphragmatic vagotomy (vgx) on the sensitivity toward noxious stimuli in rats. Vgx rats showed sustained hyperalgesia in the gastrocnemius muscle without tissue damage (no increase in vgx-induced plasma creatine phosphokinase or lactose dehydrogenase levels) accompanied by hypersensitivity to colonic distension. We found a dramatic increase in the levels of metabotropic glutamate receptor 5, protein kinase C (PKC) gamma and phosphorylated-PKCgamma within the spinal cord dorsal horn in vgx rats, which suggests that vgx may evoke sensory nerve plasticity. Morphine produced a dose-dependent increase in the withdrawal threshold in both vgx and sham-operated rats, but the effect of a lower dose in vgx rats was weaker than that in sham-operated rats. Muscle hyperalgesia in vgx rats was also attenuated by gabapentin and amitriptyline, but was not affected by diclofenac, dexamethasone or diazepam. These findings indicate that subdiaphragmatic vagal dysfunction caused chronic muscle hyperalgesia accompanied by visceral pain and both gabapentin and amitriptyline were effective for subdiaphragmatic vagotomy-induced pain, which are partially similar to fibromyalgia syndrome. Furthermore, this chronic muscle pain may result from nociceptive neuroplasticity of the spinal cord dorsal horn.

Combination use of immune complexes and a Ca2(+) channel blocker azelnidipine enhances interleukin-12 p40 secretion without T helper type 17 cytokine secretion in human monocyte-derived dendritic cells

Immune complexes (ICs) improve the capacity of priming specific CD8(+) cytotoxic T cell responses of dendritic cells (DCs). ICs induce phosphorylation of mitogen-activated protein kinases (MAPK) and calcium influx, although the precise regulating mechanism still remains unclear. In the present study, we investigated the effect of a Ca2(+) channel blocker on the phosphorylation of p38 MAPK and extracellular signal-regulated kinase (ERK) in immature monocyte-derived DCs stimulated with lipopolysaccharide (LPS) or LPS-ICs, and the production of interleukin (IL)-12 family members (p40, p70, IL-23), T helper type 17 (Th17) cytokines (IL-6 and IL-23), tumour necrosis factor (TNF)-alpha and IL-10 were also investigated. In comparison with LPS stimulation, LPS-ICs stimulation enhanced p38 MAPK phosphorylation significantly, which was associated with an increase in IL-12 p40 monomer/homodimer secretion. LPS-ICs also enhanced TNF-alpha and IL-6 secretion, but suppressed IL-23 secretion. The use of azelnidipine (Aze), a long-acting L-type Ca2(+) channel blocker with a high lipid solubility, suppressed p38 MAPK phosphorylation stimulated with LPS or LPS-ICs, but surprisingly enhanced IL-12 p40 monomer/homodimer secretion stimulated with LPS-ICs. This IL-12 p40 secretion-enhancing effect was not accompanied by IL-10 or IL-23 production, but was associated with ERK phosphorylation. The use of Aze did not affect IL-12 p70 production. These results suggest that the use of Aze enhances ICs-mediated IL-12 p40 secretion without additional IL-23 secretion. Therefore, the use of Aze and ICs could be a new therapeutic approach to immunomolecular therapy, as it does not cause Th17 differentiation which induces autoimmunity or reduces anti-tumour immunity.

Brain lesions induced by experimental intranasal infection of Japanese encephalitis virus in piglets

Non-suppurative encephalitis was experimentally induced in three-week-old piglets by a single intranasal inoculation of Japanese encephalitis virus (JEV) isolated from field pigs. The lesions consisted of glial cell aggregates and perivascular cuffing throughout the olfactory tract and pyriform cortex. JEV antigens were detected in the cytoplasm and neuronal processes of small nerve cells in the granule cell layer of the olfactory bulb, in the neuronal processes of the olfactory tract and in the cytoplasm of neurons in the pyriform cortex. The distribution of the antigens corresponded closely with the distribution of brain lesions. These findings suggest that JEV may enter the brain by the olfactory pathway in addition to via haematogenous spread in piglets.