Utility of endoscopic therapy in the management of Boerhaave syndrome

Background/aims: The optimal intervention for Boerhaave perforation has not been determined. Options include surgical repair with/without a pedicled muscle flap, T tube placement, esophageal resection or diversion, or an endoscopic approach. All management strategies require adequate drainage and nutritional support. Our aim was to evaluate outcomes following Boerhaave perforation treated with surgery, endoscopic therapy, or both. Patients and methods: We performed a 10-year review of our prospectively maintained databases of adult patients with Boerhaave perforations. We documented clinical presentation, extent of injury, primary intervention, "salvage" treatment (any treatment for persistent leak), and outcome. Results were analyzed using the Fisher's exact and Kruskal - Wallis tests. Results: Between October 2004 and October 2014, 235 patients presented with esophageal leak/fistula with 17 Boerhaave perforations. Median age was 68 years. Median length of perforation was 1.25 cm (range 0.8 - 5 cm). Four patients presented with systemic sepsis (two treated with palliative stent and two surgically). Primary endotherapy was performed for eight (50 %) and primary surgery for eight (50 %) patients. Two endotherapy patients required multiple stents. Median stent duration was 61 days (range 56 - 76). "Salvage" intervention was required in 2/8 (25 %) endotherapy patients and 1/8 (13 %) surgery patient (stent). All patients healed without resection/reconstruction. There were no deaths in the surgically treated group and two in the endotherapy group (stented with palliative intent due to poor systemic condition). Readmission within 30 days occurred in 3/6 of alive endotherapy patients (50 %) and 0/8 surgery patients. Re-intervention within 30 days was required for one endotherapy patient. Conclusion: Endoscopic repair of Boerhaave perforations can be useful in carefully selected patients without evidence of systemic sepsis. Endoscopic therapy such as stenting is particularly valuable as a "salvage" intervention. The benefits of endoscopic therapy and esophageal preservation are offset against an increased risk of readmission in patients primarily treated endoscopically.

Impact of endoscopic ultrasonography and physician specialty on the management of patients with esophagus cancer

While endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are the most accurate techniques for locoregional staging of esophageal cancer, little evidence exists that these innovations impact on clinical care. The objective on this study was to determine the frequency with which EUS and EUS-FNA alter the management of patients with localized esophageal cancer, and assess practice variation among specialists at a tertiary care center. Three gastroenterologists, three medical oncologists, three radiation oncologists and four thoracic surgeons were asked to independently report their management recommendations as the anonymized staging information of 50 prospectively enrolled patients from another study were sequentially disclosed on-line. Compared to initial management recommendations, that were based upon history, physical examination, upper endoscopy and CT scan results, EUS prompted a change in management 24% (95% CI: 12-36%) of the time; usually to a more resource-intensive approach (71%), for example from recommending palliation to recommending neoadjuvant chemoradiation therapy. EUS-FNA plus cytology results altered management an additional 8% (95% CI: 6-15%) of the time. Agreement between specialists ranged from fair (intraclass correlation [ICC=0.32) to substantial (ICC=0.65); improving with additional information. Among specialists, agreement was greatest for patients with stage I disease. EUS and EUS-FNA changed patient management the most for patients with stages IIA, IIB or III disease. EUS, with or without FNA, significantly impacts the management of patients with localized esophageal cancer. With respect to the optimal treatment for each patient, agreement among physicians incrementally increases with endoscopic ultrasound results. Specialty training appears to influence therapeutic decision-making behavior.

Porphyromonas gingivalis dihydroceramides induce apoptosis in endothelial cells

Porphyromonas gingivalis dihydroceramides are found in extracts of calculus-contaminated root surfaces, diseased gingival tissue, and atherosclerotic plaques. These ceramides have been shown to promote inflammatory secretory responses in gingival fibroblasts. Little is known about their effects on the vascular system. We tested the hypothesis that P. gingivalis lipids induce apoptosis of human endothelial cells, and investigated the effects of extracted and purified P. gingivalis lipids on human umbilical vein endothelial cells. P. gingivalis phosphoglycerol dihydroceramides induced apoptosis, but not necrosis, in endothelial cells. Early apoptotic cells showed exposure of phosphatidylserine on the cell surface, followed by the cleavage of procaspases 3, 6, and 9. The release of apoptosis-inducing factor was increased, suggesting mitochondrial involvement. Different caspase inhibitors and cAMP elevation blocked DNA fragmentation. Moreover, N-acetylcysteine significantly reduced apoptosis, suggesting a role for reactive oxygen species in this process. Analysis of these data indicates that dihydroceramides may be important virulence factors of P. gingivalis.

Percutaneous endoscopic gastrostomy risks rendering the gastric conduit unusable for esophagectomy

Surgical treatment for cancer of the esophagus most often involves replacement of the esophagus with a gastric conduit. This gastric tube relies upon the continuity of the gastroepiploic artery for its blood supply. This case report involves a patient whose gastroepiploic artery became thrombosed by a percutaneous endoscopic gastrostomy, rendering his gastric conduit unusable.

Porphyromonas gingivalis lipids and diseased dental tissues

BACKGROUND/AIM

Porphyromonas gingivalis synthesizes several classes of dihydroceramides and at least one of these lipid classes promotes proinflammatory secretory reactions in gingival fibroblasts as well as alters fibroblast morphology in culture. The purpose of this investigation was to determine whether the dihydroceramide lipids of P. gingivalis are recovered in lipid extracts of subgingival plaque, diseased teeth, and diseased gingival tissue samples.

METHODS

Lipids were extracted from P. gingivalis, subgingival plaque, subgingival calculus, teeth laden with gross accumulations of subgingival calculus, and gingival tissue samples obtained from chronic severe periodontitis sites. Lipid samples were analyzed by gas chromatography-mass spectrometry as trimethylsilyl derivatives or by electrospray-mass spectrometry as underivatized products. High-performance liquid chromatography fractions of P. gingivalis lipids and gingival tissue lipids were also analyzed by electrospray-mass spectrometry analysis.

RESULTS

P. gingivalis phosphorylated dihydroceramides were recovered in lipid extracts of subgingival plaque, subgingival calculus, calculus contaminated teeth, and diseased gingival tissue samples. However, the distribution of phosphorylated dihydroceramides varied between these samples.

CONCLUSION

Subgingival plaque, subgingival calculus, diseased teeth, and gingival tissue are contaminated with phosphorylated dihydroceramides produced by P. gingivalis. The previously reported biological activity of these substances together with the recovery of these lipids at periodontal disease sites argues strongly for their classification as virulence factors in promoting chronic inflammatory periodontal disease.

Lobar torsion after pulmonary resection: presentation and outcome

OBJECTIVE

We reviewed our experience on postoperative lobar torsion.

METHODS

Between January 1972 and January 1998, 7887 patients underwent pulmonary resection at our institution. Seven (0.089%; 4 women and 3 men; median age, 68 years) patients required surgical reintervention for lobar torsion.

RESULTS

The indications for pulmonary resection were non-small cell carcinoma in 5 patients, lymphoma in 1 patient, and metastatic prostate carcinoma in 1 patient. The right upper lobe was resected in 3 patients, the left lower lobe in 2 patients, and the right middle and right lower lobe in 1 patient each. Postoperative radiographs demonstrated pulmonary infiltrates and volume loss in 5 patients and complete opacification in 2 patients. The median white blood cell count was 10.6 x 10(9) cells/L (range, 9.3-14.9 x 10(9) cells/L), and the median peak temperature was 38.4 degrees C (range, 37.8 degrees C-40.2 degrees C) during the first 48 hours postoperatively. The diagnosis of lobar torsion was made a median of 10 days (range, 2-14 days) after the initial operation; 4 patients underwent completion pneumonectomy, and 3 had lobectomy. Median hospitalization was 24 days and ranged from 10 to 56 days. There were no postoperative deaths. Complications after reoperation included respiratory failure in 2 patients, atrial arrhythmia in 2 patients, and empyema, urinary tract infection, and a transient ischemic attack in 1 patient each.

CONCLUSIONS

Lobar torsion represents a difficult diagnostic dilemma in the early postoperative period after pulmonary resection. A high index of suspicion is necessary to avoid a delay in treatment. Late diagnosis results in further pulmonary resection and prolonged hospitalization in the majority of cases.

Laparoscopic repair of large paraesophageal hiatal hernia

BACKGROUND

The objective of this study was to analyze our initial results after laparoscopic repair of large paraesophageal hiatal hernias.

METHODS

Between October 1997 and May 2000, 37 patients (23 women, 14 men) underwent laparoscopic repair of a large type II (pure paraesophageal) or type III (combined sliding and paraesophageal) hiatal hernia with more than 50% of the stomach herniated into the chest. Median age was 72 years (range 52 to 92 years). Data related to patient demographics, esophageal function, operative techniques, postoperative symptomatology, and complications were analyzed.

RESULTS

Laparoscopic hernia repair and Nissen fundoplication was possible in 35 of 37 patients (95.0%). Median hospitalization was 4 days (range 2 to 20 days). Intraoperative complications occurred in 6 patients (16.2%) and included pneumothorax in 3 patients, splenic injury in 2, and crural tear in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating in 2, and a small bowel obstruction in 1. Two patients died within 30 days (5.4%), 1 from delayed splenic bleeding and 1 from adult respiratory distress syndrome secondary to a recurrent strangulated hiatal hernia. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Twenty-seven patients (87.1%) were improved. Four patients (12.9%) required early postoperative dilatation. Recurrent paraesophageal hiatal hernia occurred in 4 patients (12.9%). Functional results were classified as excellent in 17 patients (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%).

CONCLUSIONS

Laparoscopic repair of large paraesophageal hiatal hernias is a challenging operation associated with significant morbidity and mortality. More experience, longer follow-up, and further refinement of the operative technique is indicated before it can be recommended as the standard approach.

Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence

BACKGROUND

Factors affecting the incidence of empyema and bronchopleural fistula (BPF) after pneumonectomy were analyzed.

METHODS

All patients who underwent pneumonectomy at the Mayo Clinic in Rochester, Minnesota, from January 1985 to September 1998 were reviewed. There were 713 patients (514 males and 199 females). Ages ranged from 12 to 86 years (median 64 years). Indication for resection was primary malignancy in 607 patients (85.1%), metastatic disease in 32 (4.5%), and benign disease in 74 (10.4%). One hundred fifteen patients (16.1%) underwent completion pneumonectomy. Factors affecting the incidence of postoperative empyema and BPF were analyzed using univariate and multivariate analysis.

RESULTS

Empyema was documented in 53 patients (7.5%; 95% confidence interval [CI], 5.7% to 9.7%) and a BPF in 32 (4.5%; 95% CI, 3.1% to 6.3%). Univariate analysis demonstrated that the development of empyema was adversely affected by benign disease (p = 0.0001), lower preoperative forced expiratory volume in 1 second (FEV1; p < 0.01) and diffusion capacity of lung to carbon monoxide (DLCO; p = 0.0001), lower preoperative serum hemoglobin (p = 0.05), right pneumonectomy (p = 0.0109), bronchial stump reinforcement (p = 0.007), completion pneumonectomy (p < 0.01), timing of chest tube removal (p = 0.01), and the amount of blood transfusions (p < 0.01). Similarly, the development of BPF was significantly associated with benign disease (p = 0.03), lower preoperative FEV1 (p = 0.03) and DLCO (p = 0.01), right pneumonectomy (p < 0.0001), bronchial stump reinforcement (p = 0.03), timing of chest tube removal (p = 0.004), increased intravenous fluid in the first 12 hours (p = 0.04), and blood transfusions (p = 0.04). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (p = 0.009). No risk factors were identified as being jointly significant in multivariate analysis.

CONCLUSIONS

Multiple perioperative factors were associated with an increased incidence of empyema and BPF after pneumonectomy. Prophylactic reinforcement of the bronchial stump with viable tissue may be indicated in those patients suspected at higher risk for either empyema or BPF.

Prostaglandin E2 secretion from gingival fibroblasts treated with interleukin-1beta: effects of lipid extracts from Porphyromonas gingivalis or calculus

Complex lipids of Porphyromonas gingivalis have been identified in lipid extracts from calculus-contaminated root surfaces and in diseased gingival tissues. However, little is known about the biological effects of these complex lipids on host cells. The purpose of this study was to evaluate the effects of P. gingivalis or calculus lipids on prostaglandin secretion from gingival fibroblasts. Lipids were extracted from paired subgingival plaque and teeth samples, and calculus-contaminated root surfaces before and after scaling and root planing, in order to determine the relevant levels of lipid extracts for the treatment of gingival fibroblasts in culture. Primary cultures of gingival fibroblasts were exposed to lipid extracts from either P. gingivalis or calculus/teeth for a period of 7 days. Control and lipid-treated cultures were exposed to human recombinant interleukin-1beta for 48 h and prostaglandin secretion from interleukin-1beta-treated fibroblasts was compared with control and lipid-treated fibroblasts without interleukin-1beta treatment. These experiments demonstrated that P. gingivalis lipids or calculus-tooth lipids potentiate interleukin-1beta-mediated prostaglandin secretory responses from gingival fibroblasts. Additionally, P. gingivalis or calculus-tooth lipid extracts were readily taken up by gingival fibroblasts as measured by bacterial fatty acid recovery in lipid extracts of cultured fibroblasts. These results indicate that bacterial lipid penetration into gingival tissues in combination with a chronic inflammatory response may substantially potentiate prostaglandin secretion from gingival fibroblasts, thereby promoting tissue destructive processes associated with adult periodontitis.

Management of postpneumonectomy empyema and bronchopleural fistula

Empyema after pneumonectomy is often associated with a bronchopleural fistula (BDF) and has a significant mortality. Management options include systemic antibiotics and observation, adequate pleural drainage, appropriate parenteral antibiotics, removal of necrotic tissue, and obliteration of residual pleural space. We prefer to treat the empyema with the procedure originally described by Clagett and Geraci in 1963. They demonstrated that postpneumonectomy empyema could be successfully treated by open pleural drainage, frequent wet-to-dry dressing changes, and when the thorax was clean, secondary chest wall closure with obliteration of the pleural cavity with an antibiotic solution. Failure was most often caused by a persistent or recurrent fistula. Because of this, when a BPF is present, the original Clagett technique was modified to include transposition of a well-vascularized muscle to cover the stump at the time of open drainage to prevent further ischemia and necrosis. Our preference is intrathoracic transposition of extrathoracic skeletal muscle. The goals of therapy for postpneumonectomy empyema remain a healthy patient with a a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients by using the Clagett procedure and intrathoracic muscle transposition when a BPF is present.

Effects of a bacterial cell wall fragment on monocyte inflammatory function

Gram-negative bacteria recovered from necrotic pulps of teeth with periapical lesions have been shown to promote bone resorption through the effects of their lipopolysaccharide (LPS). Recently, it was shown that microflora of root-filled teeth with persisting periapical lesions consisted mainly of single species of Gram-positive bacteria. But Gram-positive bacteria do not contain LPS and their role in the development of periapical lesions is not clearly understood. The purpose of this study was to evaluate the effects of muramyl dipeptide (MDP), a cell wall component of both Gram-negative and Gram-positive bacteria, on cytokine release from monocytes. Human monocyte cultures were treated with MDP or LPS and interleukin-1 beta, and tumor necrosis factor-alpha levels in the supernatants were estimated. MDP and LPS stimulated cytokine release, but the effect of MDP was significantly less than that of LPS.

Novel ceramides recovered from Porphyromonas gingivalis: relationship to adult periodontitis

The primary purpose of this study was to characterize the major structural features of ceramides recovered from Porphyromonas gingivalis, a suspected periodontal pathogen. Complex lipids extracted from P. gingivalis were treated with N, O-bis(trimethylsilyl)-trifluoroacetamide and analyzed using gas chromatography-mass spectrometry. Mass spectra of lipid derivatives revealed cleavage products consistent with structures of four major ceramides. Two of the major ceramides are proposed to contain long chain bases of either 2-amino-1,3-octadecanediol or 2-amino-1, 3-nonadecanediol in amide linkage to 3-hydroxy isobranched C17:0. The remaining major ceramides are proposed to contain either 2-amino-1,3-octadecanediol or 2-amino-1,3-nonadecanediol in amide linkage to C17:1. Alkaline hydrolysis of P. gingivalis lipids and subsequent formation of suitable derivatives revealed 3-hydroxy isobranched C17:0, C17:1, 2-amino-1,3-octadecanediol, and 2-amino-1, 3-nonadecanediol as hydrolysis products. Therefore, the constitutive fatty acids and long chain bases recovered in alkaline hydrolysis products of P. gingivalis lipids are consistent with the proposed ceramide structures. The next goal of this study was to investigate whether these bacterial ceramides exist in lipid extracts of human teeth and gingival tissue at sites of severe adult periodontitis. Using selected ion monitoring of characteristic ions and retention times for each ceramide described above, lipids from teeth and gingival tissue were shown to contain primarily the ceramides containing C17:1. It is concluded that P. gingivalis synthesizes at least four major ceramides and two of these ceramides are selectively adsorbed to diseased tooth surfaces and may penetrate into diseased gingival tissue.

Management of spontaneous pneumothorax during pregnancy: case report and review of the literature

Spontaneous pneumothorax rarely occurs during pregnancy. Only 22 nonmalignancy-related cases have been previously published. Herein we report a case of recurrent spontaneous pneumothorax during the third trimester of pregnancy that necessitated surgical intervention. At thoracotomy, a large bulla was excised from the lower lobe of the right lung; abrasive pleurodesis was subsequently done. Postoperatively, the patient had regular contractions, which were successfully stopped with intravenous administration of magnesium sulfate. Indications, procedures, and pre-cautions for operative intervention during pregnancy are discussed.

Distribution of 3-hydroxy iC17:0 in subgingival plaque and gingival tissue samples: relationship to adult periodontitis

Gram-negative organisms incorporate hydroxy fatty acids into the lipid A moiety of lipopolysaccharide (LPS), and in the case of some members of the family Enterobacteriaceae, hydroxy fatty acids are incorporated exclusively into lipid A. However, a limited number of Bacteroides species have been shown to incorporate several classes of 3-hydroxy fatty acids, particularly 3-hydroxy iC17:0, into constitutive lipids as well as LPS. The present study examined the distribution of hydroxy fatty acids in two periodontal pathogens, Prevotella intermedia and Porphyromonas gingivalis, by employing a phospholipid extraction procedure (E. G. Bligh and W. J. Dyer, Can. J. Biochem. Physiol. 37:911-917, 1959) which partitioned constitutive lipids into the organic solvent phase and LPS into the aqueous phase. The distribution of hydroxy fatty acids within organic solvent and aqueous extracts of these bacterial species was then compared with the distribution in subgingival plaque samples isolated from either gingivitis or severe periodontitis sites as well as the distribution in gingival tissue samples. The organic solvent and aqueous extracts were hydrolyzed under strong alkaline conditions, and the free fatty acids were treated to form pentafluorobenzyl-ester, trimethylsilyl-ether derivatives. Hydroxy fatty acid levels were quantified by using gas chromatography-negative-ion chemical ionization-mass spectrometry. By using this approach, the mean values of the 3-hydroxy iC17:0 recovered within organic solvent extracts of P. gingivalis strains ranged from 56 to 63% of total 3-hydroxy iC17:0. Substantially less 3-hydroxy iC17:0 (< 5%) was recovered in organic solvent extracts of P. intermedia. By comparison, 75% of the 3-hydroxy iC17:0 in periodontitis subgingival plaque samples was recovered in organic solvent extracts, while only 43% of the 3-hydroxy iC17:0 in gingivitis plaque samples from the same patients was recovered in organic solvent extracts. However, 3-hydroxy iC17:0 was recovered essentially only in organic solvent extracts of both healthy or mildly inflamed and periodontitis gingival tissue samples. The preferential recovery of 3-hydroxy iC17:0 in tissue lipids indicates that gingival tissues do not harbor significant levels of subgingival plaque organisms which contain 3-hydroxy iC17:0. Furthermore, these results indicate that LPS from these organisms is not prevalent in gingival tissues. Finally, these results indicate either selective penetration of certain bacterial lipids into gingival tissues or that 3-hydroxy iC17:0 is metabolically transferred from bacterial lipids into gingival tissue lipids.

Alteration of biological properties of bacterial lipopolysaccharide by calcium hydroxide treatment

Bacterial lipopolysaccharide (LPS) plays a major role in the development of periapical bone resorption. Although the chemical properties of LPS are altered by treatment with an alkali such as calcium hydroxide, the effects of calcium hydroxide on the biological properties of LPS are not known. The purpose of this study was to investigate whether treatment of LPS with calcium hydroxide alters its biological action as measured by human monocyte secretion of prostaglandin E2. Monocyte cell cultures were stimulated with LPS or calcium hydroxide-treated LPS and culture supernatants were analyzed for prostaglandin E2 content using gas chromatography-mass spectrometry. Prostaglandin E2 was identified in supernatants of LPS-stimulated monocytes but not in those stimulated with calcium hydroxide-treated LPS. It was concluded that the treatment with calcium hydroxide may alter biological properties of bacterial LPS.

Longitudinal evaluation of peripheral blood monocyte secretory function in periodontitis-resistant and periodontitis-susceptible patients

The purpose of this investigation was to evaluate lipopolysaccharide (LPS)-stimulated monocyte secretory responses longitudinally in patients with generalized severe chronic adult periodontitis (periodontitis-susceptible) and controls with gingivitis (periodontitis-resistant). In addition, the expression of constitutive (Leu-M3) and LPS-inducible (Mo3e) antigens on monocytes isolated from these two groups was examined. Monocyte secretory function was assessed longitudinally; the effect of periodontal therapy in the susceptible patients was examined by comparing monocyte function before and after their treatment. Peripheral blood monocytes were isolated by counterflow centrifugal elutriation and treated with control medium or media containing 1 microgram/ml of Salmonella typhimurium LPS or Prevotella intermedia LPS with or without human recombinant interferon (IFN)-gamma pretreatment. Prostaglandin E2, F2 alpha and thromboxane B2 were quantified in culture samples by gas chromatography-mass spectrometry (GC-MS) and interleukin-1 beta was quantified by enzyme-linked immunosorbent assay. Leu-M3 and Mo3e antigen expression was assessed by FACScan. Three major findings were made. First, LPS-stimulated IL-1 beta release by monocytes from susceptible patients was depressed relative to that in resistant patients at the initial donation. After periodontal therapy, there was virtually identical IL-1 beta release in LPS-stimulated cultures from both groups. However, in susceptible patients IL-beta release was diminished after periodontal therapy in cultures pretreated with IFN-gamma. Second, there was a significant drift in monocyte secretion of prostaglandin E2 in samples from the resistant patients between the first two donations and the third donation. PGE2 release did not differ between groups at the initial donation, although there was a depression in PGE2 release in the susceptible group at the final donation when IFN-gamma was followed by S. typhimurium LPS.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of calcium hydroxide on bacterial lipopolysaccharide

Apical periodontitis and its concomitant periapical osteolysis is caused by pulpal infection, and bacterial lipopolysaccharide (LPS) is known to play a major role in the bone resorption process. Little is known concerning the effect of root canal intervisit dressings on residual LPS in root canals after bacterial cell lysis. The purpose of this study was to evaluate the effects of calcium hydroxide on bacterial LPS. Free hydroxy fatty acids were quantified in samples of LPS treated with calcium hydroxide. Calcium hydroxide treatment of LPS was shown to release elevated quantities of hydroxy fatty acids. It was concluded that calcium hydroxide hydrolyzed the lipid moiety of bacterial LPS, resulting in the release of free hydroxy fatty acids. This result suggests that calcium hydroxide-mediated degradation of LPS may be an important reason for the beneficial effects obtained with calcium hydroxide use in clinical endodontics.

The effects of interferon-gamma and bacterial lipopolysaccharide on CD14 expression in human monocytes

CD14 has been reported to be the lipopolysaccharide (LPS)-LPS binding protein receptor. The effects of interferon-gamma (IFN-gamma) on CD14 expression have not been clearly established. The purpose of this investigation was to examine the effects of IFN-gamma alone and IFN-gamma followed by bacterial LPS on CD14 expression. Human peripheral blood monocytes were isolated by counterflow centrifugal elutriation (CCE). Monocytes were cultured for 48 h with IFN-gamma alone or for 24 h with IFN-gamma followed by LPS for a second 24 h. IFN-gamma alone caused a down-regulation of CD14 expression, as assessed by flow cytometry, relative to CD14 expression in untreated monocytes. In addition, CD14 expression was even more significantly down-regulated after IFN-gamma pretreatment followed by either Prevotella intermedia or Salmonella typhimurium LPS. Likewise, the percentage of CD14+ monocytes decreased after IFN-gamma alone and even more dramatically after IFN-gamma treatment followed by either LPS. This study clearly demonstrated that IFN-gamma down-regulates CD14 expression and that LPS following IFN-gamma pretreatment potentiates this effect.

Spontaneous perforating hematoma of the rectum. Report of a case

Intramural hematomas of the intestine most often occur in the setting of blunt abdominal trauma. However, spontaneous hematomas can occur secondary to either hematologic disorders, or use of anticoagulant therapy. There has been no clearly documented report of a spontaneous rectal hematoma. We describe the novel treatment of a patient with a spontaneous intramural hematoma of the rectum which presented as an abdominal catastrophe.

Prostaglandin E release from human monocytes treated with lipopolysaccharides isolated from Bacteroides intermedius and Salmonella typhimurium: potentiation by gamma interferon

The purpose of this investigation was to examine gamma interferon potentiation of lipopolysaccharide (LPS) responses in human monocytes by using phenol-water-extracted (unfractionated) and highly purified LPS preparations isolated from Bacteroides intermedius and Salmonella typhimurium. Phenol-water-extracted LPS preparations from these bacteria were further purified by chromatography over Sepharose-CL-4B. LPS enrichment in pooled column fractions was assessed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and quantitation of hydroxy-fatty acid and 2-keto-3-deoxyoctulosonic acid content, protein contamination, and anthrone-reactive material. Monocyte stimulation by LPS, measured as prostaglandin E (PGE) release, was assessed with and without gamma interferon treatment. Cells were either treated simultaneously with gamma interferon and LPS or pretreated with gamma interferon prior to LPS stimulation. PGE release from counterflow-isolated monocytes was quantitated during the 0- to 24-h and 24- to 48-h culture intervals. Contrary to previous results from this laboratory, phenol-water-extracted LPS preparations from B. intermedius and S. typhimurium were similar in their capacities to stimulate PGE release from monocytes. Molecular sieve chromatography was found to remove substantial amounts of high-molecular-weight polysaccharide contaminants only from the B. intermedius LPS but did not significantly alter the potency of either B. intermedius or S. typhimurium LPS. Gamma interferon cotreatment did not potentiate the release of PGE with any of the LPS preparations tested. However, 24-h pretreatment of monocytes with gamma interferon followed by a 24-h exposure to LPS resulted in significant potentiation of PGE release over LPS alone. In addition, B. intermedium preparations were approximately threefold more potent than similarly prepared LPS isolates from S. typhimurium following gamma interferon pretreatment. These results indicate that gamma interferon can selectively potentiate the effects of B. intermedius LPS in human monocyte isolates.

Benign liver tumors

From a practical standpoint, the most important benign hepatic tumors are hepatocytic adenoma, focal nodular hyperplasia, cavernous hemangioma, and bile duct hamartoma. The surgeon needs to be familiar with the pathogenesis, gross and radiologic appearance, and natural history of each of these lesions to formulate an appropriate therapeutic plan.

LPS-elicited secretory responses in monocytes: altered release of PGE2 but not IL-1 beta in patients with adult periodontitis

Lipopolysaccharide responsiveness in human subjects was assessed through the examination of LPS-stimulated PGE2 and IL-1 beta release from counterflow isolated monocytes from patients with varying levels of periodontal destruction. This study was performed in order to investigate a possible relationship between LPS-mediated secretory responses in monocytes and susceptibility to periodontal destruction in humans. Subjects were chosen based on apparent resistance or susceptibility to disease as measured by little or no periodontal destruction versus generalized severe destruction, respectively. Because IFN-gamma can influence LPS-stimulated responses, the effect of IFN-gamma on the LPS-stimulated release of PGE2 and IL-1 beta was also assessed. Peripheral blood monocytes were separated by counterflow centrifugation and cultured (10(6)/ml/well) with control medium or medium containing LPS from Bacteroides gingivalis, B. intermedius, Actinobacillus actinomycetemcomitans, or Salmonella typhimurium, with or without 10 Units/ml recombinant IFN-gamma. Media were exchanged at 24 and 48 hours and culture supernatants assayed for both PGE2 and IL-1 beta by RIA. Patients classified as Susceptible to periodontitis demonstrated 2- to 3-fold greater PGE2 release than Resistant patients. This difference was observed with all LPS preparations over both the 0-24 hour and 24-48 h culture periods. IL-1 beta release, however, was not significantly different between patient groups. IFN-gamma did not affect the LPS-stimulated release of PGE2 but significantly enhanced the release of IL-1 beta. The IFN-gamma effects were similar for both patient groups. These findings indicate that LPS-stimulated PGE2 release from peripheral blood monocytes may correlate with susceptibility to periodontitis in human subjects.

Prostaglandin E2 and thromboxane B2 release from human monocytes treated with bacterial lipopolysaccharide

We investigated the capacity of counterflow-isolated human monocytes to independently synthesize thromboxane B2 (TxB2) and prostaglandin E2 (PGE2) when stimulated with bacterial lipopolysaccharide (LPS). Independent metabolism was confirmed by establishing different specific activities (dpm/ng) of TxB2 and PGE2 released from LPS-treated cells. For metabolites released during the initial 2-hr treatment period, the specific activity of PGE2 was approximately threefold higher than that of TxB2 regardless of labeling with [3H]arachidonic acid (AA) or [14C]AA. Cells that were pulse-labeled for 2 hr with [3H]AA demonstrated a decreasing PGE2 specific activity over 24 hr, whereas the TxB2 specific activity remained unchanged. In contrast, cells continuously exposed to [14C]AA demonstrated an increasing TxB2 specific activity that approached the level of PGE2 by 24 hr. These results suggest the presence of at least 2 cyclooxygenase metabolic compartments in counterflow-isolated monocytes. Although freshly isolated monocytes have been reported to contain variable numbers of adherent platelets, additional experiments demonstrated that counterflow-isolated platelets are not capable of releasing elevated levels of TxB2 or PGE2 when treated with LPS. It is proposed from these findings that at least two subsets of monocytes exist in peripheral blood that can be distinguished on the basis of independent conversion of AA to TxB2 and PGE2.

Lipopolysaccharide-stimulated PGE2 release from human monocytes. Comparison of lipopolysaccharides prepared from suspected periodontal pathogens

Lipopolysaccharides (LPS) prepared from the suspected periodontal pathogens Actinobacillus actinomycetemcomitans (A. a.), Bacteroides gingivalis, B. intermedius and Wolinella recta were compared to Salmonella typhimurium LPS for their capacity to stimulate prostaglandin E2 (PGE2) release from human monocytes. Counterflow isolated monocytes were cultured with control medium or media containing 10 micrograms/ml LPS. Media were then exchanged every 24 hours for a total of 72 hours. Salmonella and Wolinella LPS preparations demonstrated seven-fold greater PGE2 release than B. gingivalis and two-fold greater than A. a. and B. intermedius. PGE2 release was found to decrease over time with all LPS preparations except Wolinella. The potency of the LPS preparations is tentatively ranked as follows: Wolinella greater than or equal to Salmonella greater than A. a. greater than B. intermedius greater than or equal to B. gingivalis. These findings demonstrate that LPS preparations from suspected periodontal pathogens are capable of stimulating PGE2 release from human monocytes. The high potency and prolonged stimulation of PGE2 release with Wolinella LPS suggests unusual toxic properties that may exert a greater influence in the pathogenesis of destructive periodontal diseases.

Prostaglandin E2, prostaglandin E1 and thromboxane B2 release from human monocytes treated with C3b or bacterial lipopolysaccharide

C3b or lipopolysaccharide treatment of human peripheral blood monocytes in culture stimulates an early release of thromboxane B2 and a delayed release of prostaglandin E into culture supernatants. Immunoreactive thromboxane B2 release is maximal from 2-8 h, whereas prostaglandin E release is maximal from 16-24 h after stimulation of monocytes in culture. We further examined this process by comparing the time course of labelled prostaglandin E2, prostaglandin E1 and thromboxane B2 release from human monocytes which were pulse or continuously labelled with [3H]arachidonic acid and [14C]eicosatrienoic acid. The release of labelled eicosanoids was compared with the release of immunoreactive prostaglandin E and thromboxane B2. The time course of prostaglandin E2 release was virtually identical to the release of prostaglandin E1 in all culture supernatants regardless of labelling conditions. However, release of immunoreactive prostaglandin E paralleled the release of labelled prostaglandin E1 and E2 only for continuously labelled cultures. The release of labelled prostaglandin E1 and E2 from pulse labelled cultures paralleled the release of thromboxane B2 and not immunoreactive prostaglandin. In contrast, labelled and immunoreactive thromboxane B2, quantitated in the same culture supernatants, demonstrated similar release patterns regardless of labelling conditions. These findings indicate that the differential pattern of prostaglandin E and thromboxane B2 release from human monocytes is not related to a time-dependent shift in the release of prostaglandin E1 relative to prostaglandin E2. Because thromboxane B2 and prostaglandin E2 are produced through cyclooxygenase mediated conversion of arachidonic acid, these results further suggest that prostaglandin E2 and thromboxane B2 are independently metabolized in human monocyte populations.

Interferon-gamma potentiation of lipopolysaccharide-induced eicosanoid release from human monocytes

Interferon-gamma (IFN-gamma) can act to potentiate lipopolysaccharide (LPS)-stimulated processes in mononuclear phagocytes, including interleukin-1 release and tumoricidal activity. The present investigation examined the capacity of IFN-gamma to modulate LPS-stimulated prostaglandin E2 (PGE2) and thromboxane B2 (TxB2) release from counterflow isolated human monocytes. The release of PGE2 and TxB2 was compared for cells incubated with IFN-gamma prior to treatment with LPS and for cells treated simultaneously with IFN-gamma and LPS. Treatment of cells with IFN-gamma prior to stimulation with LPS (10 micrograms/ml, Salmonella typhimurium) resulted in elevated prostaglandin E (by immunoassay) and [3H]PGE2 release from monocytes when compared with LPS-treated cultures. In contrast, IFN-gamma pretreatment did not potentiate labeled or immunoreactive TxB2 release from LPS-treated monocytes. IFN-gamma pretreatment without LPS stimulation did not result in elevated eicosanoid release over controls. In addition, continuous treatment of monocytes with both IFN-gamma and LPS did not result in greater release of PGE2 and TxB2 than the summed individual effects of IFN-gamma and LPS. These results indicate that IFN-gamma selectively potentiates LPS-stimulated arachidonic acid conversion to PGE2 and not TxB2 in human monocytes. This effect was observed only for monocytes pretreated with IFN-gamma prior to stimulation with LPS.

Lactic acid production in mouse calvaria in vitro with and without parathyroid hormone stimulation: lack of acetazolamide effects

The effect of acetazolamide on lactic acid production in mouse calvaria explants was examined in an attempt to explain in vivo inhibition of Ca mobilization from bone by sulfonamide inhibitors of carbonic anhydrase. Lactic acid production was evaluated in 8-10-week-old CD-1 mouse calvaria over a time period consistent with acetazolamide inhibition of both PTH-stimulated and nonstimulated Ca mobilization from bone in vivo. Labeled lactate, derived from [3,4-14C]glucose, and total lactate production were determined at 2-h intervals for up to 8 h. Simultaneous assessment of 14CO2 production and [14C]pyruvate levels established that acetazolamide produced no other related metabolic effects and that the drug did not block PTH stimulation of CO2 production. Acetazolamide (4.5 X 10(-4) M) was found to have no effect on labeled or total lactate production in mouse calvaria for up to 8 h of treatment. In addition, acetazolamide did not block PTH (10(-7) M) stimulation of lactate production. However, Cl 13,850 (10(-4) M), a structural analog of acetazolamide devoid of inhibitory activity on carbonic anhydrase or Ca mobilization from bone, was shown to significantly reduce lactate production from mouse calvaria. These results, therefore, suggest that acetazolamide does not inhibit Ca mobilization from bone through inhibition of lactic acid production and fail to support a mechanistic relationship between lactic acid production and Ca mobilization from bone.