Evolution of hygrophytic plant species in the Anatolia-Caucasus region: insights from phylogenomic analyses of Cardamine perennials

BACKGROUND AND AIMS

Southwestern Asia is a significant centre of biodiversity and a cradle of diversification for many plant groups, especially xerophytic elements. In contrast, little is known about the evolution and diversification of its hygrophytic flora. To fill this gap, we focus on Cardamine (Brassicaceae) species that grow in wetlands over a wide altitudinal range. We aimed to elucidate their evolution, assess the extent of presumed historical gene flow between species, and draw inferences about intraspecific structure.

METHODS

We applied the phylogenomic Hyb-Seq approach, ecological niche analyses and multivariate morphometrics to a total of 85 Cardamine populations from the target region of Anatolia-Caucasus, usually treated as four to six species, and supplemented them with close relatives from Europe.

KEY RESULTS

Five diploids are recognized in the focus area, three of which occur in regions adjacent to the Black and/or Caspian Sea (C. penzesii, C. tenera, C. lazica), one species widely distributed from the Caucasus to Lebanon and Iran (C. uliginosa), and one western Anatolian entity (provisionally C. cf. uliginosa). Phylogenomic data suggest recent speciation during the Pleistocene, likely driven by both geographic separation (allopatry) and ecological divergence. With the exception of a single hybrid (allotetraploid) speciation event proven for C. wiedemanniana, an endemic of southern Turkey, no significant traces of past or present interspecific gene flow were observed. Genetic variation within the studied species is spatially structured, suggesting reduced gene flow due to geographic and ecological barriers, but also glacial survival in different refugia.

CONCLUSIONS

This study highlights the importance of the refugial regions of the Black and Caspian Seas for both harbouring and generating hygrophytic species diversity in Southwestern Asia. It also supports the significance of evolutionary links between Anatolia and the Balkan Peninsula. Reticulation and polyploidization played a minor evolutionary role here in contrast to the European relatives.

Human Dermal Allograft Superior Capsule Reconstruction With Graft Length Determined at Glenohumeral Abduction Angles of 20° and 40° Decreases Joint Translation and Subacromial Pressure Without Compromising Range of Motion: A Cadaveric Biomechanical Study

PURPOSE

To compare the biomechanical effects of superior capsule reconstruction (SCR) graft fixation length determined at 20° and 40° of glenohumeral (GH) abduction.

METHODS

Humeral translation, rotational range of motion (ROM), and subacromial contact pressure were quantified at 0°, 30°, and 60° of GH abduction in the scapular plane in 6 cadaveric shoulders for the following states: intact, massive rotator cuff tear, SCR with dermal allograft fixed at 20° of GH abduction (SCR 20), and SCR with dermal allograft fixed at 40° of GH abduction (SCR 40). Statistical analysis was conducted using a repeated-measures analysis of variance and a paired t test (P < .05).

RESULTS

A massive cuff tear significantly increased total ROM compared with the intact state at 0° and 60° of abduction. SCR 20 or SCR 40 did not affect ROM. Compared with the intact state, the massive cuff tear model significantly increased superior translation by an average of 4.6 ± 0.5 mm in 9 of 12 positions (P ≤ .002). Both SCR 20 and SCR 40 reduced superior translation compared with the massive cuff tear model (P < .05); however, SCR 40 significantly decreased superior translation compared with SCR 20 at 0° of abduction (P ≤ .046). Peak subacromial pressure for the massive cuff tear model increased by an average of 486.8 ± 233.9 kPa relative to the intact state in 5 of 12 positions (P ≤ .037). SCR 20 reduced peak subacromial pressure in 2 of 12 positions (P ≤ .012), whereas SCR 40 achieved this in 6 of 12 positions (P ≤ .024).

CONCLUSIONS

SCR with dermal allograft fixed at 20° or 40° of GH abduction decreases GH translation and subacromial pressure without decreasing ROM.

CLINICAL RELEVANCE

With an increasing abduction angle for graft fixation, the medial-to-lateral graft length is decreased and the graft tension is effectively increased. Surgeons may increase shoulder stability without restricting ROM by fixing the graft at higher abduction angles. However, surgeons should remain cognizant of potential graft failure due to increased tension.

Allele Sorting as a Novel Approach to Resolving the Origin of Allotetraploids Using Hyb-Seq Data: A Case Study of the Balkan Mountain Endemic Cardamine barbaraeoides

Mountains of the Balkan Peninsula are significant biodiversity hotspots with great species richness and a large proportion of narrow endemics. Processes that have driven the evolution of the rich Balkan mountain flora, however, are still insufficiently explored and understood. Here we focus on a group of Cardamine (Brassicaceae) perennials growing in wet, mainly mountainous habitats. It comprises several Mediterranean endemics, including those restricted to the Balkan Peninsula. We used target enrichment with genome skimming (Hyb-Seq) to infer their phylogenetic relationships, and, along with genomic in situ hybridization (GISH), to resolve the origin of tetraploid Cardamine barbaraeoides endemic to the Southern Pindos Mts. (Greece). We also explored the challenges of phylogenomic analyses of polyploid species and developed a new approach of allele sorting into homeologs that allows identifying subgenomes inherited from different progenitors. We obtained a robust phylogenetic reconstruction for diploids based on 1,168 low-copy nuclear genes, which suggested both allopatric and ecological speciation events. In addition, cases of plastid-nuclear discordance, in agreement with divergent nuclear ribosomal DNA (nrDNA) copy variants in some species, indicated traces of interspecific gene flow. Our results also support biogeographic links between the Balkan and Anatolian-Caucasus regions and illustrate the contribution of the latter region to high Balkan biodiversity. An allopolyploid origin was inferred for C. barbaraeoides, which highlights the role of mountains in the Balkan Peninsula both as refugia and melting pots favoring species contacts and polyploid evolution in response to Pleistocene climate-induced range dynamics. Overall, our study demonstrates the importance of a thorough phylogenomic approach when studying the evolution of recently diverged species complexes affected by reticulation events at both diploid and polyploid levels. We emphasize the significance of retrieving allelic and homeologous variation from nuclear genes, as well as multiple nrDNA copy variants from genome skim data.

Anterior Capsule Reconstruction Versus Pectoralis Major Transfer for Irreparable Subscapularis Tears Involving the Anterior Capsule: A Comparative Biomechanical Cadaveric Study

PURPOSE

To compare the biomechanical effectiveness of human dermal allograft (HDA) anterior capsular reconstruction (ACR) and pectoralis major tendon transfer (PMTT) for treating irreparable subscapularis tears with capsular insufficiency in human cadaver shoulders.

METHODS

Glenohumeral rotational range of motion and translation were measured in 6 cadaveric shoulders under the following 5 conditions: intact, deficient subscapularis/anterior capsule, ACR using HDA, HDA ACR with concomitant PMTT, and PMTT alone.

RESULTS

The deficient subscapularis/anterior capsule condition significantly increased external and total rotational range of motion at 0° (P < .001, P < .001) and 30° (P = .005, P = .002) abduction as well as anterior-inferior translation (P ≤ .001 to .03). HDA ACR, both with and without PMTT, restored anterior-inferior stability to that of the intact condition; however, PMTT alone did not restore anterior-inferior translation or rotational range of motion.

CONCLUSIONS

HDA ACR for treating irreparable subscapularis tears with capsular insufficiency restored anterior-inferior glenohumeral translation and rotational range of motion at time 0 in human cadaver shoulders.

CLINICAL RELEVANCE

Anterior capsule reconstruction may be a viable option for treating massive irreparable subscapularis tears with capsular insufficiency.

A biomechanical cadaveric study of patellar tendon allograft as an alternative graft material for superior capsule reconstruction

HYPOTHESIS

In a cadaveric irreparable rotator cuff tear model, patellar tendon allograft-superior capsule reconstruction (PT-SCR) will restore glenohumeral stability and reduce subacromial contact pressures without significant graft deformation during testing.

METHODS

Eight cadaveric shoulders were tested in a custom shoulder testing system. Rotational range of motion (ROM), superior translation, and subacromial contact pressure were measured in the following experimental conditions: intact rotator cuff, irreparable supraspinatus tear (massive cuff tear [MCT]), and PT-SCR.

RESULTS

MCT and PT-SCR resulted in significantly increased total ROM at all degrees of abduction compared with the intact state (P < .001). In both 0° and 30° of glenohumeral abduction, MCT showed a significant increase in superior translation compared with the intact state (P < .001). Application of the PT-SCR resulted in a decrease of superior translation compared with MCT (P < .001). At 0° abduction/60° external rotation and 0° abduction/90° external rotation, MCT showed significantly greater peak subacromial contact pressure compared with the intact state (P < .006). At both of these positions, PT-SCR was able to reduce peak pressure to lower than or no significant difference from the intact state. There was no statistically significant change in graft thickness, length, or width after testing.

CONCLUSION

PT-SCR was able to reduce superior translation of the humeral head and peak subacromial contact pressure without restricting ROM. Furthermore, there was no significant graft deformation during testing. PT-SCR in this validated cadaveric model demonstrates favorable biomechanical properties and is a viable source of graft material for SCR.

Effect of Increased Scapular Internal Rotation on Glenohumeral External Rotation and Elbow Valgus Load in the Late Cocking Phase of Throwing Motion

BACKGROUND

Scapular dyskinesis among throwers is thought to affect kinetic chain function and increase the load demands on the shoulder and/or elbow. However, the biomechanical relationship between scapular orientation and elbow valgus load, which is associated with ulnar collateral ligament (UCL) injury, has not been determined.

PURPOSE

To evaluate the effect of increased scapular internal rotation (IR) and glenohumeral external rotation (GHER) on elbow valgus load in a static simulation of the late cocking phase of throwing.

STUDY DESIGN

Controlled laboratory study.

METHODS

Seven fresh-frozen male cadaveric upper extremities were used with a custom testing system to simulate the late cocking phase. First, the authors evaluated the effect of increasing scapular IR on maximum GHER and forearm angle (forearm axis relative to the ground). Each parameter was evaluated at 20° to 40° (5° increments) of scapular IR by applying 2.2-N·m external rotation torque to the humerus and 0.75-N·m valgus torque to the forearm. Next, to evaluate elbow valgus stability, the humerus was locked in maximal GHER at 40° of scapular IR, and sequentially increasing torque (0.75-7.5 N·m by 0.75-N·m increments) was applied to the forearm. Valgus angle and joint gap were evaluated at each torque.

RESULTS

Increases in scapular IR ≥5° significantly decreased GHER ( P < .01). With increasing valgus torque, forearm angle also increased linearly ( R² = 0.85, P < .001). To compensate for the GHER deficit at 40° of scapular IR, a linear regression model showed that 25.3 N·m of valgus torque would be necessary to reach the original forearm position. In the intact condition, applying elbow valgus torque ≥5.25 N·m significantly increased valgus angle and the joint gap ( P < .01).

CONCLUSION

Increased scapular IR significantly decreased GHER. Compensation for the GHER deficit significantly increased the elbow valgus load required to reach the same forearm position.

CLINICAL RELEVANCE

Increased scapular IR may increase the risk of elbow UCL injury among throwing athletes.

Anterior Cable Reconstruction Using the Proximal Biceps Tendon for Large Rotator Cuff Defects Limits Superior Migration and Subacromial Contact Without Inhibiting Range of Motion: A Biomechanical Analysis

PURPOSE

To assess an anterior cable reconstruction (ACR) using autologous proximal biceps tendon for large to massive rotator cuff tears.

METHODS

Nine cadaveric shoulders (mean age, 58 years) were tested with a custom testing system. Range of motion, superior translation of the humeral head, and subacromial contact pressure were measured at 0°, 30°, 60°, and 90° of external rotation (ER) with 0°, 20°, and 40° of glenohumeral abduction. Five conditions were tested: intact, stage II tear (supraspinatus), stage II tear + ACR, stage III tear (supraspinatus + anterior half of infraspinatus), and stage III tear + ACR. ACR involved a biceps tendon tenotomy at the transverse humeral ligament, preserving its labral attachment. ACR included nonpenetrating suture-loop fixation using 2 side-to-side sutures and an anchor at the articular margin to restore anatomy and secure the tendon along the anterior edge of the cuff defect. ACR was performed in 20° glenohumeral abduction and 60° ER.

RESULTS

ACR for both stage II and stage III showed significantly higher total range of motion compared with intact at all angles (P ≤ .001). ACR significantly decreased superior translation for stage II tears at 0°, 30°, and 60° ER for both 0° and 20° abduction (P ≤ .01) and for stage III tears at 0° and 30° ER for both 0° and 20° abduction (P ≤ .004). ACR for stage III tear significantly reduced peak subacromial contact pressure at 30° and 60° ER with 0° and 40° abduction and at 30° ER with 20° abduction (P ≤ .041).

CONCLUSIONS

ACR using autologous biceps tendon biomechanically normalized superior migration and subacromial contact pressure, without limiting range of motion.

CLINICAL RELEVANCE

ACR may improve rotator cuff tendon repair longevity by providing basic static ligamentous support to the dynamic tendon while helping to limit superior migration without restricting glenohumeral kinematics.

Cardiac Donor Risk Factors Predictive of Short-Term Heart Transplant Recipient Mortality: An Analysis of the United Network for Organ Sharing Database

INTRODUCTION

To address the shortage of donor hearts for transplantation, there is significant interest in liberalizing donor acceptance criteria. Therefore, the aim of this study was to evaluate cardiac donor characteristics from the United Network for Organ Sharing (UNOS) database to determine their impact on posttransplantation recipient outcomes.

METHODS

Adult (≥18 years) patients undergoing heart transplantation from July 1, 2004, to December 31, 2012, in the UNOS Standard Transplant Analysis and Research (STAR) database were reviewed. Patients were stratified by 1-year posttransplantation status; survivors (group S, n = 13,643) and patients who died or underwent cardiac retransplantation at 1-year follow-up (group NS/R = 1785). Thirty-three specific donor variables were collected for each recipient, and independent donor predictors of recipient death or retransplantation at 1 year were determined using multivariable logistic regression analysis.

RESULTS

Overall 1-year survival for the entire cohort was 88.4%. Mean donor age was 31.5 ± 11.9 years, and 72% were male. On multivariable logistic regression analysis, donor age >40 years (odds ratio [OR] 1.44, 95% confidence interval [CI] 1.27 to 1.64), graft ischemic time >3 hours (OR 1.32, 1.16 to 1.51), and the use of cardioplegia (OR 1.17, 1.01 to 1.35) or Celsior (OR 1.21, 1.06 to 1.38) preservative solution were significant predictors of recipient death or retransplantation at 1 year posttransplantation. Male donor sex (OR 0.83, 0.74 to 0.93) and the use of antihypertensive agents (OR 0.88, 0.77 to 1.00) or insulin (OR 0.84, 0.76 to 0.94) were protective from adverse outcomes at 1 year.

CONCLUSIONS

These data suggest that donors who are older, female, or have a long projected ischemic time pose greater risk to heart transplant recipients in the short term. Additionally, certain components of donor management protocols, including antihypertensive and insulin administration, may be protective to recipients.

Stainless steel surface functionalization for immobilization of antibody fragments for cardiovascular applications

Stainless steel 316 L material is commonly used for the production of coronary and peripheral vessel stents. Effective biofunctionalization is a key to improving the performance and safety of the stents after implantation. This paper reports the method for the immobilization of recombinant antibody fragments (scFv) on stainless steel 316 L to facilitate human endothelial progenitor cell (EPC) growth and thus improve cell viability of the implanted stents for cardiovascular applications. The modification of stent surface was conducted in three steps. First the stent surface was coated with titania based coating to increase the density of hydroxyl groups for successful silanization. Then silanization with 3 aminopropyltriethoxysilane (APTS) was performed to provide the surface with amine groups which presence was verified using FTIR, XPS, and fluorescence microscopy. The maximum density of amine groups (4.8*10(-5) mol/cm(2)) on the surface was reached after reaction taking place in ethanol for 1 h at 60 °C and 0.04M APTS. On such prepared surface the glycosylated scFv were subsequently successfully immobilized. The influence of oxidation of scFv glycan moieties and the temperature on scFv coating were investigated. The fluorescence and confocal microscopy study indicated that the densest and most uniformly coated surface with scFv was obtained at 37 °C after oxidation of glycan chain. The results demonstrate that the scFv cannot be efficiently immobilized without prior aminosilanization of the surface. The effect of the chemical modification on the cell viability of EPC line 55.1 (HucPEC-55.1) was performed indicating that the modifications to the 316 L stainless steel are non-toxic to EPCs.

Portable double-sided laser-heating system for Mössbauer spectroscopy and X-ray diffraction experiments at synchrotron facilities with diamond anvil cells

The diamond anvil cell (DAC) technique coupled with laser heating is a major method for studying materials statically at multimegabar pressures and at high temperatures. Recent progress in experimental techniques, especially in high-pressure single crystal X-ray diffraction, requires portable laser heating systems which are able to heat and move the DAC during data collection. We have developed a double-sided laser heating system for DACs which can be mounted within a rather small (~0.1 m(2)) area and has a weight of ~12 kg. The system is easily transferable between different in-house or synchrotron facilities and can be assembled and set up within a few hours. The system was successfully tested at the High Pressure Station of White Beam (ID09a) and Nuclear Resonance (ID18) beamlines of the European Synchrotron Radiation Facility. We demonstrate examples of application of the system to a single crystal X-ray diffraction investigation of (Mg(0.87),Fe(3+) (0.09),Fe(2+) (0.04))(Si(0.89),Al(0.11))O(3) perovskite (ID09a) and a Synchrotron Mössbauer Source (SMS) study of (Mg(0.8)Fe(0.2))O ferropericlase (ID18).

BX90: a new diamond anvil cell design for X-ray diffraction and optical measurements

We present a new design of a universal diamond anvil cell, suitable for different kinds of experimental studies under high pressures. Main features of the cell are an ultimate 90-degrees symmetrical axial opening and high stability, making the presented cell design suitable for a whole range of techniques from optical absorption to single-crystal X-ray diffraction studies, also in combination with external resistive or double-side laser heating. Three examples of the cell applications are provided: a Brillouin scattering of neon, single-crystal X-ray diffraction of α-Cr(2)O(3), and resistivity measurements on the (Mg(0.60)Fe(0.40))(Si(0.63)Al(0.37))O(3) silicate perovskite.

Superhard semiconducting optically transparent high pressure phase of boron

An orthorhombic (space group Pnnm) boron phase was synthesized at pressures above 9 GPa and high temperature, and it was demonstrated to be stable at least up to 30 GPa. The structure, determined by single-crystal x-ray diffraction, consists of B12 icosahedra and B2 dumbbells. The charge density distribution obtained from experimental data and ab initio calculations suggests covalent chemical bonding in this phase. Strong covalent interatomic interactions explain the low compressibility value (bulk modulus is K300=227 GPa) and high hardness of high-pressure boron (Vickers hardness HV=58 GPa), after diamond the second hardest elemental material.

Interaction between LIS1 and doublecortin, two lissencephaly gene products

Mutations in either LIS1 or DCX are the most common cause for type I lissencephaly. Here we report that LIS1 and DCX interact physically both in vitro and in vivo. Epitope-tagged DCX transiently expressed in COS cells can be co-immunoprecipitated with endogenous LIS1. Furthermore, endogenous DCX could be co-immunoprecipitated with endogenous LIS1 in embryonic brain extracts, demonstrating an in vivo association. The two protein products also co-localize in transfected cells and in primary neuronal cells. In addition, we demonstrate homodimerization of DCX in vitro. Using fragments of both LIS1 and DCX, the domains of interaction were mapped. LIS1 and DCX interact with tubulin and microtubules. Our results suggest that addition of DCX and LIS1 to tubulin enhances polymerization in an additive fashion. In in vitro competition assays, when LIS1 is added first, DCX competes with LIS1 in its binding to microtubules, but when DCX is added prior to the addition of LIS1 it enhances the binding of LIS1 to microtubules. We conclude that LIS1 and DCX cross-talk is important to microtubule function in the developing cerebral cortex.

Who represents managed care?

Managed care-related trade associations are more than just legislative advocates. Faced with a competitive marketplace and an overlap in membership from the sheer number of associations, these groups now offer a multitude of services, such as on-line job matching, resource guides, discounts on related professional services, and public relations assistance.

[Serotonin re-uptake inhibitors as primary therapy for carotid sinus hypersensitivity]

Carotid sinus syndrome is a well-recognized cause of unexplained syncope in older patients, and may, lead to significant morbidity due to trauma from falls. Dual chamber pacing has been shown to be effective in relieving symptoms due to bradycardia, but not due to vasodepressor response. We report an 84-year-old man with recurrent syncope due to carotid sinus hypersensitivity. He was treated only with a serotonin reuptake inhibitor and was symptom-free after 3 weeks of therapy. He has remained symptom-free for the past year.

Molecular characterization of the replicon of the Pediococcus pentosaceus 43200 pediocin A plasmid pMD136

The pediocin A-encoding plasmid of Pediococcus pentosaceus 43200, pMD136, was characterized by restriction enzyme analysis. Analysis of its replicon was facilitated by the construction of a probe vector consisting of the Escherichia coli plasmid pSP72 and the cat gene from Staphylococcus aureus plasmid pC194. The replication region of pMD136 was localized on a 1.6-kb EcoRI/BglII fragment. Sequencing analysis revealed a non-coding region, repA, spanning the first 440 bp, followed by an open reading frame, repB, encoding a putative protein of 390 amino acids. The non-coding region contained two sets of 6-bp and two sets of 22-bp direct repeats and two sets of inverted repeats upstream of the open reading frame. Strong homology of the isolated replicon was found to theta-type replicons of Lactococcus lactis plasmids. Segregational stability assay suggested at least two regions as potentially involved in the stabilization of pMD136. The plasmid's strong homology to other theta-type replicons and its relatively high stability suggest that pMD136 belongs to the widespread family of theta-replication plasmids.

Large-scale preparation and characterization of recombinant ovine placental lactogen

To clone ovine placental lactogen (oPL) cDNA, total RNA from sheep placental cotyledon was reverse transcribed and the single-stranded cDNA was PCR-amplified with 5' and 3' primers containing, respectively, NcoI and PstI sites. The oPL cDNA fragment amplified between these two primers extended from A(-1) to the natural stop codon. The PCR product was gel-purified and subcloned into a Puc vector and the insert was sequenced on both strands, revealing several differences relative to the published sequence: S19N, S69N, D129E and R165Q. We assume that these differences can be accounted for by the high level of individual polymorphism, which has been described in detail for PLs of different species. The insert was subcloned into NcoI/ PstI-digested pTrc99A procaryotic expression plasmid and protein expression was induced by isopropyl-1-thio-beta-D-galactopyranoside. Because of low expression, oPL's cDNA was further subcloned into pET8 procaryotic expression plasmid. Its expression in E. coli strain BL21 transformed with this vector yielded 30-40 mg/l. The expressed protein, found in the inclusion bodies, was refolded into a monomer and purified on a Q-Sepharose column to homogeneity. Structural analysis using circular dichroism revealed a spectrum similar to that of human GH (hGH) thereby indicating proper refolding. Gel filtration and binding experiments, including real-time kinetic measurements using the surface plasmon resonance method revealed that oPL forms transient homodimeric complexes with extracellular domains of prolactin receptors from rabbit, rat and bovine and with hGH receptor. The purified oPL was biologically active in an Nb2-11C cell proliferation bioassay, in its ability to stimulate beta-casein synthesis in explants of ovine and rabbit mammary gland and fat synthesis in explants of bovine mammary gland, and in a proliferation assay using FDC-P1 cells transfected with rabbit or hGH receptors.

CT findings in pediatric gastrointestinal ascariasis

We present a case of a 9-yr-old child with gastrointestinal ascariasis. Computed tomography of the abdomen demonstrates the Ascaris roundworms as cylindrical filling defects within contrast filled bowel loops. In addition, the intestinal tract of the roundworm itself is seen as a thin thread of oral contrast within the tubular filling defect. To our knowledge, this is the first reported description of the CT findings of intestinal ascariasis in a pediatric patient.

Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis

OBJECTIVES

The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis.

METHODS

Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest.

RESULTS

Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients).

CONCLUSIONS

(1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.

Femoral torsion after interlocked nailing of unstable femoral fractures

OBJECTIVE

The determination of rotation of the femur during intramedullary nailing procedures can be difficult, particularly when the fracture pattern does not lend itself to interdigitation. We studied 22 patients who had isolated femur fractures treated by closed intramedullary nailing to determine the degree of malrotation introduced at the time of surgery.

DESIGN AND METHODS

Anteversion of the affected and normal femora was determined by a standard computed tomography (CT) torsion study. The range of motion of the hip was measured in the prone position. Foot progression angles (FPAs) were measured in 14 patients who were fully ambulatory for at least 6 months.

MAIN RESULTS

The average malrotation of the fractured femur was 16 degrees (4 to 61 degrees). The median malrotation was 14 degrees. The differences in CT-measured anteversion (delta A), FPA (delta FPA), internal rotation (delta IR), and external rotation (delta ER) between the affected and normal sides were determined. Linear regression was used to analyze delta A with delta FPA, delta IR, and delta ER. Changes in internal and external rotation as determined by physical exam had a stronger correlation with delta A than did delta FPA. This indicates that malrotation of the femur is accommodated for during gait.

CONCLUSIONS

Based on this data, we found that anteversion of the normal femur can be determined in the operating room using the image intensifier and can be duplicated on the fractured side using the described technique in cases where comminution prevents fragmentational alignment. This method has been used for 12 patients in a prospective trial, and malrotation has been kept to under 10 degrees in all cases.

Ectopic supernumerary kidney: another cause of a pelvic mass

Ectopic supernumerary pelvic kidney is a rare cause of a pelvic mass in the adolescent populations. We present a case of an ectopic supernumerary pelvic kidney, found incidentally, on a computed axial tomographic (CT) examination.

Epidemic AIDS-related Kaposi's sarcoma in southern Africa: experience at the Johannesburg General Hospital (1980-1990)

Epidemic acquired immune deficiency syndrome-related Kaposi's sarcoma (AKS) in tropical and southern Africa is a highly varied neoplastic disease, characterized by multifocal mucocutaneous, lymphatic and visceral involvement. It follows a clinical course similar to AKS in Europe and the USA. However, lack of adequate medical facilities in many African countries hampers successful palliation of this fatal disease. In this retrospective analysis, we summarize our experience with 52 patients with AKS treated at Johannesburg General Hospital, South Africa, between 1980 and 1990. Radiation therapy can provide good to excellent palliation with only minimal side-effects, producing a lesser impact on the haematological and immunological system than chemotherapy.

Radiation Therapy in Epidemic, Aids-Related Kaposi's Sarcoma in Southern Africa

Aims and background

Acquired Immunodeficiency Syndrome (AIDS) associated Kaposi's Sarcoma (EKS) is widely spread in the Southern African Region. No large studies concerning the role of radiation therapy in the Southern African variant of EKS have been reported to date.

Methods

Over a 10 year period (1982-1992) 25 patients with EKS (disseminated skin involvement) were treated primarily with radiation therapy at the Johannesburg General Hospital. Radiation fields were individually tailored to the extent of the disease. Total administered doses ranged between 8-12 Gy (single fraction) to 24-30 Gy fractionated over 2-3 weeks.

Results

Overall response and symptomatic relief rates were 72% and 80%, respectively. Toxicity was mild and manageable.

Conclusions

Our retrospective analysis supports the use of radiation therapy for the Southern African type of EKS.

Radiation Therapy in an Elderly African Population with Kaposi's Sarcoma

There are no published studies on the efficacy of modern radiation therapy in elderly populations with the endemic African type of Kaposi's sarcoma (AKS). The present retrospective analysis of 20 elderly AKS patients treated by radiotherapy attempts to supply information relevant to the older age group. It demonstrates that excellent symptomatic relief with minimal side effects can be attained and suggests that the role of radiotherapy as the treatment of choice in this particular group should be emphasized.

Malignant lymphoma with primary cardiac manifestations: a case report

This case report describes a 29-year-old black patient presenting with right heart failure secondary to massive lymphomatous cardiac involvement. Additional sites of involvement included mesenteric lymph nodes and the small bowel. Malignant lymphoma with primary cardiac manifestations is very rare and follows an aggressive course. The importance of early diagnosis and commencement of immediate therapy is emphasized.

Classical Kaposi's sarcoma in Caucasians in Africa--experience at the Johannesburg Hospital (1978-1992)

The data are scant concerning classical Kaposi's sarcoma (CKS) among the Caucasian population of Africa. A description of the clinical features of 15 such patients, treated and followed up at the Johannesburg General Hospital over a 14-year period (1978-1992) is presented. All patients were negative for the human immunodeficiency virus. After a mean follow-up of 50 months (range: 7-168 months), 2 patients are alive with absent or minimal disease; 1 patient is alive with stable disease and 1 has active disease involving his extremities. Three patients were lost to follow-up but had minimal or no disease when last seen. Five patients died of unrelated causes but also had minimal or no disease at their last visit. One patient died of sepsis related to active KS. Only two patients died of progressive KS. No alterations in humoral or cellular immunity were demonstrated in 2 patients with persistent disease. Four (27%) patients developed lymphoproliferative disorders including non-Hodgkin's lymphoma, Waldenström's macroglobulinemia, Hodgkin's disease and Castleman's disease (angiofollicular lymph node hyperplasia) preceding or following the diagnosis of CKS. These data confirm the indolent nature and good outcome of the classical form of Kaposi's sarcoma among Caucasians in the southern African region. The marked association between CKS and lymphoproliferative disorders warrants a long-term awareness and continued monitoring for these complications.

Malrotation of the bowel: malalignment of the superior mesenteric artery-vein complex shown by CT and MR

A malposition of the superior mesenteric vein on cross-sectional imaging was seen in four adult patients with malrotation of the bowel and is diagnostic of this entity. This sign should be looked for on CT or magnetic resonance to explain ill defined symptomatology and to define who may be at risk for future complications. We also define a "pseudo-superior mesenteric artery-vein sign" due to mass displacement of the pancreas, which must be distinguished from true malrotation.

The role of interventional radiology in the management of genitourinary trauma

The role of the radiologist in the management of urologic disease has changed dramatically in the last 10 years with the introduction of new imaging methods and the evolution of the angiographic catheter into a therapeutic instrument. The authors review the diagnostic options in genitourinary trauma, the indications for and techniques of transcatheter arterial embolization for renal and other retroperitoneal hemorrhage, and nonvascular interventions such as antegrade nephrostomy, stenting of urethral disruptions, percutaneous bladder drainage, and drainage of abscesses, hematomas, and urinomas.

Percutaneous insertion of the Kimray-Greenfield filter: incidence of femoral vein thrombosis

Venograms were obtained in 17 patients 5-8 days after percutaneous dilatation of the common femoral vein for insertion of the Kimray-Greenfield inferior vena cava filter. The venograms showed thrombosis of the common femoral vein in seven (41%) of the 17 patients, four of whom were symptomatic. Common femoral vein thrombosis can have serious clinical sequelae. The possibility of this complication should be considered before inserting the filter percutaneously via the femoral vein.

Bladder cancer risk and pipes, cigars, and smokeless tobacco

Interview data from 2982 patients with bladder cancer and 5782 controls selected from the general population were used to assess the effects of non-cigarette tobacco use on bladder cancer risk. Compared to men who had never smoked, those who had smoked pipes but not cigars or cigarettes had a relative risk estimated at 1.23 (95% confidence interval [CI] = 0.75-2.00). Those who smoked cigars but not pipes or cigarettes were estimated to have a relative risk of 1.33 (95% CI = 0.92-1.94). Little evidence of dose response was observed. The excess relative risk to pipe smokers was limited to those who inhaled deeply.