Comparison of Extracellular Vesicles from Induced Pluripotent Stem Cell-Derived Brain Cells

The pathophysiology of many neuropsychiatric disorders is still poorly understood. Identification of biomarkers for these diseases could benefit patients due to better classification and stratification. Exosomes excreted into the circulatory system can cross the blood-brain barrier and carry a cell type-specific set of molecules. Thus, exosomes are a source of potential biomarkers for many diseases, including neuropsychiatric disorders. Here, we investigated exosomal proteins produced from human-induced pluripotent stem cells (iPSCs) and iPSC-derived neural stem cells, neural progenitors, neurons, astrocytes, microglia-like cells, and brain capillary endothelial cells. Of the 31 exosome surface markers analyzed, a subset of biomarkers were significantly enriched in astrocytes (CD29, CD44, and CD49e), microglia-like cells (CD44), and neural stem cells (SSEA4). To identify molecular fingerprints associated with disease, circulating exosomes derived from healthy control (HC) individuals were compared against schizophrenia (SCZ) patients and late-onset Alzheimer's disease (LOAD) patients. A significant epitope pattern was identified for LOAD (CD1c and CD2) but not for SCZ compared to HC. Thus, analysis of cell type- and disease-specific exosome signatures of iPSC-derived cell cultures may provide a valuable model system to explore proteomic biomarkers for the identification of novel disease profiles.

Neuronal Stem Cells from Late-Onset Alzheimer Patients Show Altered Regulation of Sirtuin 1 Depending on Apolipoprotein E Indicating Disturbed Stem Cell Plasticity

Late-onset Alzheimer's disease (AD) is a complex multifactorial disease. The greatest known risk factor for late-onset AD is the E4 allele of the apolipoprotein E (APOE), while increasing age is the greatest known non-genetic risk factor. The cell type-specific functions of neural stem cells (NSCs), in particular their stem cell plasticity, remain poorly explored in the context of AD pathology. Here, we describe a new model that employs late-onset AD patient-derived induced pluripotent stem cells (iPSCs) to generate NSCs and to examine the role played by APOE4 in the expression of aging markers such as sirtuin 1 (SIRT1) in comparison to healthy subjects carrying APOE3. The effect of aging was investigated by using iPSC-derived NSCs from old age subjects as healthy matched controls. Transcript and protein analysis revealed that genes were expressed differently in NSCs from late-onset AD patients, e.g., exhibiting reduced autophagy-related protein 7 (ATG7), phosphatase and tensin homolog (PTEN), and fibroblast growth factor 2 (FGF2). Since SIRT1 expression differed between APOE3 and APOE4 NSCs, the suppression of APOE function in NSCs also repressed the expression of SIRT1. However, the forced expression of APOE3 by plasmids did not recover differently expressed genes. The altered aging markers indicate decreased plasticity of NSCs. Our study provides a suitable in vitro model to investigate changes in human NSCs associated with aging, APOE4, and late-onset AD.

[An unusually painful leg ulcer in an 81-year-old patient: an interdisciplinary challenge]

An 81-year-old male patient with a history of peripheral arterial disease (PAD) was admitted to the authors' outpatient clinic with a painful lower leg ulcer. As the degree of PAD did not correspond to the clinical findings, multiple biopsies were taken from the base and edge of the ulcer. This resulted in the histopathological and clinical diagnosis of pyoderma gangrenosum (PG). Since PG is often associated with numerous underlying diseases, further thorough examinations were performed. A mass in the gastric antrum suspicious for malignancy was histopathologically identified as gastric cancer (signet ring cell carcinoma). The PG was successfully treated with cortisone p.o. and tacrolimus ointment. Since the cancer was locally limited, the patient underwent surgery involving gastric resection with D2 lymphadenectomy and gastrojejunostomy (Roux-en‑Y anastomosis).

Presentation of a Sedation Standard Using the Example of Transesophageal Echocardiographies (TEE) in Pediatric Outpatients

Introduction Most pediatric patients require deep sedation for a TEE examination. We analyzed the data of our sedation protocols relating to all outpatient TEEs in patients under 18 years of age for the year 2011. On the basis of the data records of a total of 40 patients, we will describe our standard and compare it with the findings of the international literature. Material and Methods In a retrospective analysis, we inspected our sedation protocols in terms of patient-related data, vital parameters, drug applications, occurring complications and necessary interventions as well as nausea and vomiting during the post-sedative monitoring phase. Results In line with our standard, we applied atropine, midazolam, S-ketamine and propofol; complications occurred in 5 patients. They could be handled using simple measures. With regard to the vital parameters, no severe complications occurred. Dizziness was observed in 4 patients during the recovery phase; one patient complained about nausea and vomiting during the first fluid intake. All patients could be discharged 4 h after the termination of sedation. Conclusion Our standard is a practicable and safe procedure for preforming TEE examinations in pediatric outpatients.

Autologous skeletal-muscle-derived cell injection for anal incontinence due to obstetric trauma: a 5-year follow-up of an initial study of 10 patients

AIM

Our aim was to determine whether the benefits of autologous skeletal-muscle-derived cell injection to treat obstetric anal incontinence are sustained at 5 years.

METHOD

An observational study was performed of 10 women suffering from obstetric anal incontinence refractory to non-surgical therapy. Autologous skeletal-muscle-derived cells were injected into the external sphincter defect under ultrasound guidance. Incontinence diaries and quality of life questionnaires were obtained pre-implantation and annually after implantation for 5 years. Anal physiology testing was performed before implantation and at 1, 2 and 5 years after implantation. The end-points included were adverse events, Wexner incontinence scores, incontinence episodes, anal squeeze pressures and quality of life over 5 years. An independent statistician used multilevel linear regression to analyse changes in repeated measures over time. Any skewed distributions were log transformed prior to analysis.

RESULTS

No procedure-related adverse events occurred and haematological and biochemical parameters were normal during the 5-year period. There were sustained significant improvements in the Wexner incontinence score and reduced frequency of defaecation and number of incontinence episodes (all comparisons P < 0.001). Anal resting and squeeze pressures showed sustained improvement (all P < 0.001) and quality of life improved overall (P < 0.001), including all submeasures studied (P < 0.001).

CONCLUSION

Autologous skeletal-muscle-derived cells to treat obstetric anal incontinence resulted in sustained improvement in incontinence episodes, physiological measurements of anal function and quality of life at 5 years.

Surgical options to treat constipation: A brief overview

Patients with intractable chronic constipation should be evaluated with physiological tests after structural disorders and extracolonic causes have been excluded. Conservative treatment options should be tried unstintingly. It should be pointed out that especially new drugs such as prucalopride and linaclotide seem to be a big step forward in treating patients with chronic constipation. If surgery is indicated, for many years subtotal colectomy with IRA was the treatment of choice, although segmental resections were also a good option for isolated megasigmoid, sigmoidocele or recurrent sigmoid volvulus. Nowadays, less invasive procedures like sacral nerve modulation (SNM) should be tried first. If unsuccessful, colectomy can still be considered. In general, patients with a gastrointestinal dysmotility syndrome (GID) should not be offered any surgical options because of their anticipated poor results. Moreover, patients with psychiatric disorders should be actively discouraged from resection, as they tend to have a poorer prognosis. Patients must be counseled that pain and/or bloating will likely persist even if surgery normalizes bowel frequency. Patients with associated problems may be better served by having a stoma without resection as both a therapeutic maneuver and a diagnostic trial. Colectomy is not an option for the treatment of pain and/or abdominal bloating. In most cases outlet obstruction can be treated successfully with a conservative approach. However, nowadays there are also a variety of surgical options on the market. Each technique has its special place in the armamentarium of a colorectal surgeon but its exact role is not defined yet.The aim of this article is to give a brief overview, how to diagnose and treat chronic constipation from the standpoint of a colorectal surgeon.Surgical treatment of chronic constipation is not routine and is performed only in exceptional cases. But one thing first: a "too long gut" (dolichocolon) per se is never an indication for surgery. The aim of this manuscript is to give a brief overview about possible mechanisms of constipation, diagnostic methods and tools and the various conservative and operative treatment options. Moreover, please always keep in mind that constipation may not only be a symptom, but even a distinct disease!

Binding characteristics of [3H]-JSM10292: a new cell membrane-permeant non-peptide bradykinin B2 receptor antagonist

BACKGROUND AND PURPOSE

A (3) H-labelled derivative of the novel small-molecule bradykinin (BK) B(2) receptor antagonist JSM10292 was used to directly study its binding properties to human and animal B(2) receptors in intact cells and to closely define its binding site.

EXPERIMENTAL APPROACH

Equilibrium binding, dissociation and competition studies with various B(2) receptor ligands and [(3) H]-JSM10292 were performed at 4°C and 37°C. The experiments were carried out using HEK293 cells stably (over)expressing wild-type and mutant B(2) receptors of human and animal origin.

KEY RESULTS

[(3) H]-JSM10292 bound to B(2) receptors at 4°C and at 37°C with the same high affinity. Its dissociation strongly depended on the temperature and increased when unlabelled B(2) receptor agonists or antagonists were added. [(3) H]-JSM10292 is cell membrane-permeant and thus also bound to intracellular, active B(2) receptors, as indicated by the different 'nonspecific' binding in the presence of unlabelled JSM10292 or of membrane-impermeant BK. Equilibrium binding curves with [(3) H]-JSM10292 and competition experiments with unlabelled JSM10292 and [(3) H]-BK showed a different affinity profile for the wild-type B(2) receptor in different species (man, cynomolgus, rabbit, mouse, rat, dog, pig, guinea pig). Characterization of B(2) receptor mutants and species orthologues combined with homology modelling, using the CXCR4 as template, suggests that the binding site of JSM10292 is different from that of BK but overlaps with that of MEN16132, another small non-peptide B(2) receptor ligand.

CONCLUSIONS AND IMPLICATIONS

[(3) H]-JSM10292 is a novel, cell membrane-permeant, high-affinity B(2) receptor antagonist that allows direct in detail studies of active, surface and intracellularly located wild-type and mutant B(2) receptors.

Guidelines for the management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group

The purpose of this guideline is to provide a decision aid for diagnosis, treatment, and follow-up of patients with major perineal tears and thus minimize the risk of persistent symptoms. In 2007, the "Guideline for the management of third and fourth degree perineal tears after vaginal birth" was established by members of the Austrian Urogynecologic Working Group (AUB). The guideline was updated in 2011, including literature published up to 30 November 2011. The DELPHI method was used to reach consensus. Evidence-based and consensus-based statements were defined for epidemiology, risk factors, classification, diagnosis, surgery, and follow-up of major perineal lacerations at vaginal birth.

Surgical management of lower gastrointestinal bleeding

PURPOSE

Lower gastrointestinal bleeding (LGIB) is any form of bleeding distal to the Ligament of Treitz. In most cases, acute LGIB is self-limited and resolves spontaneously with conservative management.

METHODS

Only a minority of approximately 10% is admitted to hospital with signs of massive bleeding and shock requiring resuscitation, urgent evaluation and treatment.

RESULTS

Over the past decade, there has been a progressive decrease in upper GI events and a significant increase in lower GI events. Overall, mortality has also decreased, but in-hospital fatality due to upper or lower GI complications have remained constant. The problem is that LGIB can arise from a number of sources and may be a significant cause of hospitalisation and mortality in elderly patients.

CONCLUSIONS

After initial resuscitation, the diagnosis and treatment of LGIB remains a challenge for acute care surgeons, whereby the identification of the source of bleeding is of utmost importance.

The surgical anatomy and etiology of gastrointestinal fistulas

BACKGROUND

Fistulas are abnormal communications between two epithelial surfaces, either between two portions of the intestine, between the intestine and some other hollow viscus, or between the intestine and the skin of the abdominal wall. The etiology of intestinal fistulas is in most cases a result of multiple contributing factors. Despite significant advances in their management over the past decades, intestinal fistulas remain a major clinical problem, with a high overall mortality rate of up to 30% due to the high rate of complications. This paper aims to describe classification systems based on the anatomy, physiology and etiology that may be helpful in the clinical management of intestinal fistulas.

METHODS

On the basis of anatomical differences, fistulas can be classified based by the site of origin, by site of their openings, or as simple or complex. Physiologic classification as low, moderate or high output fistulas is most useful for the non-surgical approach. Concerning the etiology, we classified the possible causes as (postoperative) trauma, inflammation, infection, malignancy, radiation injury or congenital.

CONCLUSION

Fistula formation can cause a number of serious or debilitating complications ranging from disturbance of fluid and electrolyte balance to sepsis and even death. They still remain an important complication following gastrointestinal surgery.

Muscle-derived cell injection to treat anal incontinence due to obstetric trauma: pilot study with 1 year follow-up

OBJECTIVE

To treat anal incontinence due to obstetric external anal sphincter disruption via injection of autologous myoblast cells.

DESIGN

Observational pilot study.

SETTING

University hospital and district hospital

PATIENTS

10 women suffering from anal incontinence due to obstetric anal sphincter injury, refractory to conventional non-surgical therapy.

INTERVENTIONS

Autologous myoblasts were cultured from a pectoralis muscle biopsy, harvested, and injected into the external anal sphincter defect using direct ultrasound guidance.

MAIN OUTCOME MEASURES

Wexner incontinence score, anal squeeze pressures, and quality of life 12 months after injection. Safety and technical feasibility.

RESULTS

The procedure was well tolerated and no adverse events were observed. At 12 months the Wexner incontince score had decreased by a mean of 13.7 units (95% CI, -16.3 to -11.2), anal squeeze pressures were unchanged, and overall quality of life scores improved by a median of 30 points (95% CI, 25 to 42). Anal squeeze pressures did rise significantly at 1 month and 6 months post-injection (p = 0.03).

CONCLUSIONS

Injection of autologous myoblasts is safe, well tolerated, and significantly improves symptoms of anal incontinence due to obstetric anal sphincter trauma.

Management of complications in surgery of the colon

BACKGROUND

General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly.

METHODS

We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads).

RESULTS

Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision®, Ligasure®) as well as a well coordinated team help to reduce complications and duration of surgery.

CONCLUSIONS

To avoid is better than to repair. If complications do occur, appropriate surgical and intensive - care measures should be taken immediately.

Anorectal manometry: are fatigue rate and fatigue rate index of any clinical importance?

BACKGROUND

Loss of voluntary contraction of the external anal sphincter is thought to be a factor in fecal incontinence. During anal manometry, computerized systems produce several parameters including fatigue rate (FR), which is the basis for calculating the fatigue rate index (FRI). Our aim was to evaluate FR and FRI and their clinical importance in patients suffering from fecal incontinence or severe constipation.

MATERIALS AND METHODS

All patients scheduled for an anal physiology work-up were included in the study. FR was determined by a computer program and FRI was calculated manually with the following equation: FRI (minutes) = [squeeze pressure (mm Hg) - resting pressure (mmHg)] / - FR (mmHg/min). FR and FRI were compared in patients suffering from fecal incontinence (group I) and severe constipation (group II). Furthermore, subgroups (<50 and > or = 50 years of age) were compared. Lastly, a possible relation between length of the high-pressure zone (HPZ) and FR and FRI was assessed.

RESULTS

Between January 2000 and December 2004, 131 patients (96 with fecal incontinence, 35 with constipation) were studied. Both FR and FRI were similar between groups I and II; no significant differences were found when younger and older patients were compared within the same group. We also did not find any relation between HPZ length and either FR or FRI.

CONCLUSIONS

FR and FRI do not seem to be helpful in routine colorectal practice for evaluating the strength of the external anal sphincter.

Quality of life after sphincteroplasty

The operative technique of sphincteroplasty is only for isolated disruption of the sphincter muscle. Patients best suited for surgical corrections are those in whom incontinence is secondary to an anterior (obstetrical) sphincter defect. Due to the disappointing long-term results, the operation may be postponed if appropriate. At present, firstline treatment often is a biofeedback training program. It is well known that a persistent defect after repair is associated with an immediate poor outcome From 1995 - 2003 we have performed 40 sphincteroplasty on 38 patients with a mean age of 34 (range 19 - 71) years. The long-term results the of sphincteroplasty are not so promising. 3 techniques are available for measuring quality of life: Descriptive measures. Severity measures, Impact measures Sphincteroplasty, despite poor long-term results, is the best surgical treatment option for isolated, preferably anterior sphincter defects.

Should we treat hemorrhoids according to the stage

Hemorrhoidal disease is a very common and widespread disease, and it is estimated that about one subject out of three may suffer from this pathology. Hemorrhoids generally cause symptoms when enlarged, inflamed, thrombosed, or prolapsed. Internal hemorrhoids arise above the dentate line (in comparison to external hemorrhoids perianal phlebothrombosis) and are covered by transitional or columnar epithelium. Scleotherapy is one of the oldest therapy forms mainly for bleeding hemorrhoids. The so called Barron ligature is an office procedure in which a small rubber band is placed at the base of the internal hemorrhoid with a special applicator.

Acute pseudo-obstruction of the small intestine following high-dose chemotherapy and stem cell support

BACKGROUND

Acute intestinal pseudo-obstruction is a potentially life-threatening disease which is characterized by massive dilation of the colon or small intestine without mechanical obstruction and may develop after surgery or severe illness.

PATIENTS AND METHODS

We report 2 cases in which acute small intestinal pseudo-obstruction occurred after high-dose chemotherapy and autologous stem cell support. In 1 patient explorative abdominal laparoscopy was performed to rule out mechanical ileus. However, after having initiated treatment with acetylcholinesterase inhibitors a prompt small intestinal decompression was observed in both patients.

CONCLUSIONS

Acetylcholinesterase inhibitors should be considered as an early conservative intervention in the treatment of acute intestinal pseudo-obstruction to avoid surgery of patients undergoing high-dose chemotherapy with autologous stem cell support.

Partial splenectomy in cystic fibrosis patients with hypersplenism

We report three cystic fibrosis (CF) patients with hypersplenism who underwent partial splenectomy. The postoperative course was uneventful in two patients; one patient developed a complication necessitating resection of the rest of the spleen. Haematological parameters improved and oesophageal varices regressed in all patients. On follow up, one patient showed a normal spleen, the other a normally functioning accessory spleen; the third patient again developed splenomegaly with hypersplenism. Partial splenectomy is a promising therapeutic option for CF patients with hypersplenism.

Nonoperative treatment of blunt splenic injury

A spleen-preserving program was implemented at the author's institution during the mid-1980s using a five-part injury-grading scale that is similar and comparable to the AAST classification. Since that time, all patients with splenic injuries admitted to the Department of Surgery at the Karl-Franzens University Hospital in Graz, a level I trauma center, have been prospectively evaluated with respect to splenic preservation. Analysis of the relation of the severity of organ injury to the use of nonoperative management showed that degree I or II injuries were treated nonoperatively, whereas degree III and IV injuries were usually treated with adhesives, partial resection, or mesh splenorrhaphy; only degree V injuries almost always required splenectomy. With increasing experience in nonoperative management of splenic injuries the initial criteria have become less rigid, and there is now a tendency to attempt it in patients who formerly would have undergone surgery.

A polymorphism in the endothelin-A receptor gene predicts survival in patients with idiopathic dilated cardiomyopathy

AIMS

The endothelin system plays a role in the complex pathophysiology of idiopathic dilated cardiomyopathy. We investigated whether genetic polymorphisms of the endothelin system might be associated with dilated cardiomyopathy-related cardiac phenotypes and differences in disease outcome.

METHODS

One hundred and twenty-five unrelated dilated cardiomyopathy patients of a well characterized dilated cardiomyopathy cohort were genotyped for six common polymorphisms of the endothelin-1, endothelin-A (ETA) and endothelin-B (ETB) receptor genes using hybridization with allele-specific oligonucleotides.

RESULTS

The H323H (C/T) polymorphism in exon 6 of the ETA receptor gene was significantly associated with a shorter survival time after diagnosis. The odds ratio for carriers of the less frequent ET(A)T allele to die within 2 years after diagnosis was 5.5 (95% confidence interval, 1.4 to 21.0, P=0.013) compared to non-carriers. Kaplan-Meier analysis revealed a significantly different survival time for T allele carriers as compared to non-carriers as tested by logrank (P=0.0196), Breslow (P=0.0195), and Tarone tests (P=0.020). The influence of the ETA H323H polymorphism on survival remained significant when known predictors of prognosis such as left ventricular ejection fraction, left ventricular end-diastolic diameter, age and NYHA functional classification were entered in a Cox proportional hazards analysis. In this model, end-diastolic diameter showed a trend to influence survival (P=0.07) but only the ETA H323H polymorphism (P=0.0029) was a significant independent predictor of survival.

CONCLUSIONS

Our results suggest that genetic variation in the ETA receptor predicts survival in dilated cardiomyopathy patients, which might have important consequences for the identification of high-risk individuals.

Chromosome 22q dosage in composite extrarenal rhabdoid tumors: clonal evolution or a phenotypic mimic?

Composite extrarenal rhabdoid tumors (CERTs) represent a diverse group of neoplasms with rhabdoid shape in combination with one of several distinctive tumor types. Like the classic renal and extrarenal malignant rhabdoid tumor (MRT), as well as the atypical teratoid/rhabdoid tumor (AT/RT) of the central nervous system, CERTs typically show aggressive clinical behavior. Deletions and mutations of the INII gene on 22q11.2 have been identified in most classic MRTs and AT/RTs; however, it is not known whether the rhabdoid components in CERTs have similar genetic abnormalities. Using fluorescence in situ hybridization (FISH) on archival, paraffin-embedded tissue with a commercially available probe in close proximity to the INII locus (bcr), as well as other chromosome 22 probes, we studied 4 cases of MRT, 13 of AT/RT, and 16 of CERT (3 melanoma, 4 meningioma, 7 carcinoma, 1 rhabdomyosarcoma, and 1 neuroblastoma). Deletion of the 22q11.2 locus was demonstrated in 10 (77%) of 13 AT/RTs and 3 (75%) of 4 MRT, including 1 congenital MRT. Of the 16 CERTs, only 2 (a rhabdoid meningioma and a carcinoma with rhabdoid features; 13%) harbored a deletion at this locus. This difference was statistically significant (P <.001). We conclude that deletion of 22q11.2, typical of most classic MRTs and AT/RTs, is infrequently seen in CERTs. This suggests that the rhabdoid component of CERTs does not evolve by way of the genetic alteration characteristic of MRTs or AT/RTs, but represents instead a distinct phenotype shared by a number of tumors as they undergo anaplastic progression.

New approaches to molecular profiling of tissue samples

Figures on http://www.esacp.org/acp/2000/20-1/best.htm.

Laparoscopic cholecystectomy using 2-mm instruments

Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallbladder disorders. It minimizes effects of the operation that are independent of the gallbladder, such as trauma to the abdominal wall and other soft tissue. The surgical wounds were even smaller when 2-mm trocars were used. Laparoscopic cholecystectomy using 2-mm instruments was performed in a consecutive series of 14 patients with symptomatic gallstones. The procedure was completed in 12 cases, with conversion to open surgery in two cases. Intraoperative cholangiography was always performed. The postoperative course was always uneventful. The cosmetic effect was highly satisfactory. The procedure using 2-mm instruments could be indicated in selected patients with uncomplicated gallstone disease.

Comparative study between intra-anal sponge and needle electrode for electromyographic evaluation of constipated patients

PURPOSE

The aim of this study was to compare the intra-anal sponge electrode with the conventional needle electrode for electromyography of the pelvic floor in constipated patients.

MATERIALS AND METHODS

Forty consecutive patients (27 females) with a mean age of 64.3 (range, 15-87) years who had chronic constipation were prospectively evaluated for electromyographic evidence of nonrelaxation or paradoxical contraction of the puborectalis and external anal sphincter during simulated defecation. The soft intra-anal sponge electrode and then the concentric needle electrode were used in each patient as an internal control. Furthermore, in all patients, cinedefecography was used as an independent standard to confirm the diagnosis. Agreement was calculated using the kappa statistic.

RESULTS

Confirmation of needle electromyography was noted in 19 of 20 patients (95 percent) who had sponge electromyographic evidence of paradoxical activity. Similarly, concurrence was noted in 19 of 20 patients (95 percent) with normal relaxation of the puborectalis observed with the sponge electrode. Agreement between needle and sponge electromyography was very good (kappa = 0.9), between needle electromyography and cinedefecography was fair (kappa = 0.4), and between sponge electromyography and cinedefecography was moderate (kappa = 0.5). Furthermore, needle electromyography was more painful in all patients compared with sponge electromyography.

CONCLUSION

The soft sponge surface intra-anal electrode is an excellent alternative to the needle electrode for assessment of puborectalis activity in constipated patients. Sponge electromyography has the advantage of being as accurate as, but less painful than, needle electromyography.

Laceration of a benign adrenal adenoma mimicking a splenic rupture

Lacerations of adrenal tumors are very rare events and have been described for myelolipoma, pheochromocytoma, and cortisol-producing adenoma. We report on a patient who was admitted with suspected splenic rupture. Computed tomography showed a mass 14 cm in diameter adjacent to the spleen, but selective angiography revealed blood supply by the left suprarenal artery. A ruptured adrenal tumor was therefore diagnosed and resected. No hormone production was detected. Histologically a benign adrenal adenoma was found. Frequency, diagnosis and therapy of adrenal masses are discussed.

Comparison of three perineal procedures for the treatment of rectal prolapse

BACKGROUND

The optimal surgical procedure for the management of rectal prolapse is still under debate. Therefore, the aim of this study was to compare the short-term outcome of three perineal procedures in patients with rectal prolapse.

METHODS

Between April 1989 and April 1995, all consecutive patients who had Delorme's procedure, perineal rectosigmoidectomy, or perineal rectosigmoidectomy with levatoroplasty for full-thickness rectal prolapse were clinically and physiologically assessed before and after surgery. A standard incontinence scoring system, based on the frequency and type of incontinence (0 = full continence, 20 = complete incontinence), was used to compare the results of each procedure. Additionally, morbidity and mortality and clinical and functional outcome were evaluated and compared.

RESULTS

The study group of 61 patients who had perineal procedures for rectal prolapse included 55 women and 6 men, with a mean age of 75 years (range, 48 years to 101 years); 16 patients died of comorbid conditions between 3 months and 42 months after surgery. There were statistically significant differences among the groups relative to short-term recurrence rates, postoperative incontinence scores, mean resection length, coloanal anastomotic stricture, and leak. However, preoperative and postoperative anal manometry did not reveal statistically significant changes within or between the groups.

CONCLUSIONS

Perineal rectosigmodectomy with levatoroplasty has the best short-term outcome for the treatment of rectal prolapse.

Clinical evaluation of Acuvue contact lenses with UV blocking characteristics

BACKGROUND

In response to increasing scientific evidence which indicates that ultraviolet radiation (UVR) is a potential threat to ocular health, Acuvue contact lenses (Vistakon, Johnson & Johnson Vision Products Inc., Jacksonville, Florida) have been developed which incorporate an ultraviolet (UV) blocker within the lens polymer. Data are presented for the first clinical evaluation of Acuvue lenses with UV blocking characteristics.

METHOD

A double-masked, multicenter, prospective clinical trial involving 94 subjects was conducted. The study followed a randomized, parallel group design and consisted of 3 months of daily wear with two-weekly lens replacement. Two thirds of the subjects (61) wore the test lenses (Acuvue with UV blocker) and the remaining subjects (33) wore conventional Acuvue lenses (without UV blocker).

RESULTS

Biomicroscopic evaluations indicated that the performance of the test and control lenses was clinically similar. No clinically relevant differences between the test and control lenses were noted in the subjective assessments of vision, comfort, or handling. In addition, no differences were shown for surface deposition, lens durability, visual acuity, and subjective symptoms.

CONCLUSION

The study findings indicate that the addition of a UV blocker to Acuvue contact lenses has been achieved without affecting daily wear clinical performance. Because there is increasing evidence to suggest that the ocular tissues may be damaged by UVR, it is prudent for eye care practitioners to prescribe contact lenses that offer the benefits of both regular replacement and UV protection.

Local nitroglycerin for treatment of anal fissures: an alternative to lateral sphincterotomy?

PURPOSE

Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study.

METHODS

The study included 35 patients with acute and chronic anal fissures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures.

RESULTS

In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was observed. The healing rate after one month was 80 percent (11 acute (91.6 percent); 5 chronic (62.5 percent)) in Group A and was significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent)).

DISCUSSION

Previously increased maximum resting pressures decreased from a mean value of 110 to 87 cm H2O. This represents a mean reduction of 20 percent (P = 0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm H2O (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported.

CONCLUSIONS

Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.

Bacterial antigen delivery systems: phagocytic processing of bacterial antigens for MHC-I and MHC-II presentation to T cells

Using an in vitro model system we have studied parameters of both bacteria and antigen presenting cells that influence peptide presentation by murine major histocompatibility complex class II (MHC-II) and class I (MHC-I) molecules. To study MHC-II presentation, the HEL (52-61) epitope, which binds the murine MHC-II molecule I-Ak, was expressed as the cytoplasmic Crl-HEL fusion protein in S. typhimurium. When murine peritoneal macrophages mediated phagocytic processing of S. typhimurium expressing Crl-HEL, HEL (52-61) was processed and presented on I-Ak more efficiently from heat-killed S. typhimurium than from viable bacteria, and from a rough LPS strain compared to its isogenic smooth LPS counterpart, most likely due to enhanced phagocytosis of the rough LPS strain. Macrophages also processed phoP S. typhimurium strains with greater efficiency for peptide presentation by I-Ak than wild type bacteria while Salmonella constitutively expressing phoP were processed for peptide presentation by I-Ak less efficiently than wild type Salmonella. We have also shown that macrophage phagocytosis of E. coli or S. typhimurium results in presentation of bacterial antigens by MHC-I molecules. To investigate the role of post-Golgi MHC-I molecules in this presentation pathway, peritoneal macrophages from TAP1-/- mice, which are deficient in presenting endogenous antigens on MHC-I and lack significant surface MHC-I expression, were co-incubated with bacteria containing the 257-264 epitope from ovalbumin [OVA(257-264)], which binds the murine class I molecule Kb. Peritoneal macrophages from TAP1-/-/ mice could process bacteria expressing the OVA epitope for recognition by epitope-specific T hybridoma cells. This processing and presentation was reduced in efficiency between three to 100 fold compared to C57BL/6 macrophages, depending on the protein harbouring the OVA (257-264) epitope (Crl-OVA or native OVA). This suggests that the protein context of the OVA (257-264) epitope influences the extent of TAP-independent processing for MHC-I presentation. In addition, we show that murine bone marrow-derived dendritic cells can phagocytose and process viable gram negative bacteria for peptide presentation on MHC-I and MHC-II; inhibition studies showed that acidic compartments in dendritic cells are required for this presentation. These results suggest that dendritic cells may be potential antigen presenting cells used in eliciting specific immune responses against bacteria.

Are interpretations of video defecographies reliable and reproducible?

Video defecography is a dynamic investigation which can influence surgical decision making in constipated patients. A study was therefore undertaken to assess the inter and intraobserver variability in video defecography. Specifically, we sought to assess the interpretation of video defecographies by a group of observers with the same training, guidelines and standards. To determine interobserver variation, four independent observers, two blinded to the patient's history, reviewed 100 randomly sequenced video defecographies performed in constipated patients. The presence or absence of sigmoidocele, rectocele, intussusception or prolapse was noted. Adequate or improper function of the puborectalis, anal canal opening, anorectal angle (ARA) and grade of emptying of the rectum were also assessed. Two weeks after the initial assessment, intraobserver variation was determined by a repeat blinded review of unlabelled randomly sequenced studies. The results of interobserver accuracy for sigmoidoceles, rectoceles, intussusception, rectal prolapse, rectal emptying, opening of the anal canal, puborectalis contraction and straightening of the ARA and rectal emptying were 89.5%, 46.0%, 87.5%, 97.5%, 86.5%, 88.5%, 83.0%, and 80.0%, respectively. The intraobserver variations were 88.5%, 83.8%, 80.5%, 94.5%, 77.0%, 84.8%, 80.5% and 85.5%, respectively. Prior knowledge of the patient's history did not significantly influence the outcome. In summery, video defecography has an overall accuracy of 83.3% and as such is a valid tool in assessing constipated patients.