Abdominal Pain and Examination of Hernial Orifices: The Forgotten Art of Physical Diagnosis

Introduction: Acute abdominal pain can be the first manifestation of a hernial pathology. The estimated risk of incarcerated hernia is 1%-3% over a person's lifetime. Therefore, hernial orifice examination should be conducted routinely, especially in cases of abdominal pain. We hypothesized that physical examination of hernial orifices is not routinely performed and documented in patients presenting with acute abdominal pain.

Methods: A retrospective chart review of 100 patients who were evaluated for abdominal pain over a three-month time frame at our institution.

Results: From the 100 reviewed cases, the hernial orifice examination was performed in two cases by an Internal Medicine or Emergency Medicine physician (2%). Out of the eight cases with General Surgery consultation, only one case had hernial orifices examination (12.5%). In the 10 cases with Gastroenterology consultation, not a single case had hernial orifice examination.

Conclusion: We demonstrate that hernial examination is infrequently performed in clinical practice and suggest that emphasis should be placed on the efficient performance of physical examination and maintain the art of physical diagnosis.

Signet ring cell carcinoma of ampulla of Vater in a young adult

Signet ring cell carcinoma of the ampulla of Vater is extremely rare. The 7 cases reported earlier have been in older patients. We report a 32-year-old lady with this condition, who also had metastases in the bone marrow, vertebrae, lungs and liver.

Generation of replication-defective helper-free vectors based on simian immunodeficiency virus

A systematic study on generating simian immunodeficiency virus (SIV)-based vectors was carried out. The goal was to generate helper-free, replication-defective SIVmac-based vectors at high titers. The general approach was to cotransfect into human 293T cells a plasmid carrying the vector construct along with two helper plasmids that together expressed the SIVmac virion proteins. Initial vectors carried the bacterial beta-galactosidase gene (beta-gal). These vectors had a technical difficulty: "pseudotransduction" of beta-gal protein produced during the 293T cell transfections. As a result, infection of cultures with these vector stocks also resulted in passive transfer into, and X-gal staining of, cells that had not actually been infected by the vector. A second generation of vectors expressing the enhanced jellyfish green fluorescence protein (EGFP) was not subject to this artifact. A systematic study of the SIVmac-based EGFP vectors was carried out. Helper-free vector stocks were obtained when helper plasmids lacking the SIVmac packaging signals were used. By employing envelope helper plasmids derived from different SIVmac isolates, it was possible to generate SIVmac-based vectors pseudotyped with envelope proteins of different cell tropism. Optimization of vector and helper plasmid structures, transfection conditions, and infection procedures ultimately yielded vector titers in excess of 10(6)/ml.