A randomized prospective controlled trial of laparoscopic extraperitoneal hernia repair and mesh-plug hernioplasty: a study of 315 cases

Inguinal hernias can be repaired by traditional methods, tension-free, mesh-plug hernioplasty, and the less conventional laparoscopic techniques that have the added advantage of quicker recovery. Between September 1994 and September 1997, a prospective randomized controlled trial was performed on 292 patients with a total of 315 hernias. Of these, 150 patients with 169 hernias underwent the extraperitoneal laparoscopic repair (TEP) and 142 patients with 146 hernias were treated with mesh-plug hernioplasty. Patients were examined at 1 week after surgery and every 4 months thereafter for 3 years. Operative results, postoperative recovery, complications, and recurrences were recorded. Follow-up was complete for 89% of the patients. The average operative time was 31.5 minutes for the TEP and 30.5 minutes for the mesh-plug hernioplasty. The average operative time for the last 75 laparoscopic cases was 20 minutes, 10 minutes shorter than the open-surgery group. The overall recurrence rate was (2.5%) for the TEP and (3%) for the mesh-plug hernioplasty. Patients undergoing the laparoscopic repair consumed less narcotic analgesic and returned to their normal activity 1 week sooner than the open-surgery group. A median of 8 days vs. 15 days was required for patients to return to work, respectively, in the TEP and open-surgery group (p<0.01). Intraoperative complications occurred in two patients (1.3%) in the TEP repair. Both had peritoneal tear that mandated conversion to the TAPP repair. There were no major postoperative complications. A total of 20 (13%) minor postoperative complications occurred in the TEP. Thirty-three (23%) minor complications occurred in the open-surgery group (p<0.01). Ninety-eight percent of the patients were discharged the same day in the open-surgery group compared to 100% in the laparoscopy group. Patients with inguinal hernias who undergo extraperitoneal laparoscopic repair have the same recurrences and hospital stay but recover more rapidly, consume less analgesic, and have fewer minor complications than those who undergo the mesh-plug hernioplasty.

A comparative immunohistochemical study of peritoneal and ovarian serous tumors, and mesotheliomas

The distinction between serous neoplasms of the peritoneum in women and conventional mesothelioma can be difficult. In order to determine any significant immunohistochemical differences, formalin-fixed, paraffin-embedded sections of 10 peritoneal serous tumors (PST), 10 ovarian serous tumors (OST), and 10 epithelial mesotheliomas were evaluated with a panel of 10 antibodies directed against carcinoembryonic antigen (CEA: polyclonal, monoclonal), high molecular weight keratin (34 beta E12), low molecular weight keratin (35 beta H11), Leu-M1, TAG-72 (monoclonal antibody B72.3), human milk fat globulin (HMFG-2), vimentin, placental alkaline phosphatase (PLAP), and S-100 protein. The antibodies CEA, Leu-M1, and B72.3 had the most discriminatory value in differentiating serous tumors from mesothelioma. Eighty-five percent of PSTs and OSTs (17 of 20) were positive with CEA, Leu-M1, and/or B72.3. None of the mesotheliomas stained for CEA or Leu-M1; three mesotheliomas had very focal positivity with B72.3 (1% or less). Vimentin, PLAP, HMGF-2, keratin, and S-100 had no significant discriminatory value. Epithelial mucin was present in 80% of serous tumors, while the mesotheliomas lacked epithelial mucin. Leu-M1, CEA, and/or B72.3 positivity in a peritoneal tumor supports a diagnosis of serous tumor. However, since some PST do not stain for any of the three antibodies and the focal nature of positive reactions in some cases may be difficult to interpret, exclusion of mesotheliomas is enhanced by the use of mucin stains.

Evaluation of Metabolic and Synaptic Dysfunction Hypotheses of Alzheimer's Disease (AD): A Meta-Analysis of CSF Markers

BACKGROUND

Alzheimer's disease (AD) is currently incurable and a majority of investigational drugs have failed clinical trials. One explanation for this failure may be the invalidity of hypotheses focusing on amyloid to explain AD pathogenesis. Recently, hypotheses which are centered on synaptic and metabolic dysfunction are increasingly implicated in AD.

OBJECTIVE

Evaluate AD hypotheses by comparing neurotransmitter and metabolite marker concentrations in normal versus AD CSF.

METHODS

Meta-analysis allows for statistical comparison of pooled, existing cerebrospinal fluid (CSF) marker data extracted from multiple publications, to obtain a more reliable estimate of concentrations. This method also provides a unique opportunity to rapidly validate AD hypotheses using the resulting CSF concentration data. Hubmed, Pubmed and Google Scholar were comprehensively searched for published English articles, without date restrictions, for the keywords "AD", "CSF", and "human" plus markers selected for synaptic and metabolic pathways. Synaptic markers were acetylcholine, gamma-aminobutyric acid (GABA), glutamine, and glycine. Metabolic markers were glutathione, glucose, lactate, pyruvate, and 8 other amino acids. Only studies that measured markers in AD and controls (Ctl), provided means, standard errors/deviation, and subject numbers were included. Data were extracted by six authors and reviewed by two others for accuracy. Data were pooled using ratio of means (RoM of AD/Ctl) and random effects meta-analysis using Cochrane Collaboration's Review Manager software.

RESULTS

Of the 435 identified publications, after exclusion and removal of duplicates, 35 articles were included comprising a total of 605 AD patients and 585 controls. The following markers of synaptic and metabolic pathways were significantly changed in AD/controls: acetylcholine (RoM 0.36, 95% CI 0.24-0.53, p<0.00001), GABA (0.74, 0.58-0.94, p<0.01), pyruvate (0.48, 0.24-0.94, p=0.03), glutathione (1.11, 1.01- 1.21, p=0.03), alanine (1.10, 0.98-1.23, p=0.09), and lower levels of significance for lactate (1.2, 1.00-1.47, p=0.05). Of note, CSF glucose and glutamate levels in AD were not significantly different than that of the controls.

CONCLUSION

This study provides proof of concept for the use of meta-analysis validation of AD hypotheses, specifically via robust evidence for the cholinergic hypothesis of AD. Our data disagree with the other synaptic hypotheses of glutamate excitotoxicity and GABAergic resistance to neurodegeneration, given observed unchanged glutamate levels and decreased GABA levels. With regards to metabolic hypotheses, the data supported upregulation of anaerobic glycolysis, pentose phosphate pathway (glutathione), and anaplerosis of the tricarboxylic acid cycle using glutamate. Future applications of meta-analysis indicate the possibility of further in silico evaluation and generation of novel hypotheses in the AD field.

Periodontal Inflammation Primes the Systemic Innate Immune Response

The presence of periodontal diseases (PDs) often strongly correlates with other severe chronic inflammatory conditions, including cardiovascular disease, diabetes, and arthritis. However, the mechanisms through which these diseases interact are unclear. In PD, tissue and bone destruction in the mouth is driven by elevated recruitment of polymorphonuclear neutrophils (PMNs), which are primed and recruited from the circulation to sites of inflammation. We predicted that systemic effects on PMN mobilization or priming could account for the interaction between PD and other inflammatory conditions. We tested this using a mouse model of ligature-induced PD and found elevated PMN counts specifically in bone marrow, supporting a systemic effect of periodontal tissue inflammation on PMN production. In contrast, mice with induced peritonitis had elevated PMN counts in the blood, peritoneum, and colon. These elevated counts were further significantly increased when acute peritonitis was induced after ligature-induced PD in mice, revealing a synergistic effect of multiple inflammatory events on PMN levels. Flow cytometric analysis of CD marker expression revealed enhanced priming of PMNs from mice with both PD and peritonitis compared to mice with peritonitis alone. Thus, systemic factors associated with PD produce hyperinflammatory PMN responses during a secondary infection. To analyze this systemic effect in humans, we induced gingival inflammation in volunteers and also found significantly increased activation of blood PMNs in response to ex vivo stimulation, which reverted to normal following resolution of gingivitis. Together, these results demonstrate that periodontal tissue inflammation has systemic effects that predispose toward an exacerbated innate immune response. This indicates that peripheral PMNs can respond synergistically to simultaneous and remote inflammatory triggers and therefore contribute to the interaction between PD and other inflammatory conditions. This suggests larger implications of PD beyond oral health and reveals potential new approaches for treating systemic inflammatory diseases that interact with PD.

A comparative study of laparoscopic extraperitoneal and transabdominal preperitoneal herniorrhaphy

Laparoscopic minimally invasive surgical procedures are gaining popularity. Laparoscopic hernia repair is now less controversial and more readily acceptable, with at present numerous technical modifications described in an attempt to define the best procedure. Between November 1992 and February 1995, a nonrandomized trial of laparoscopic inguinal herniorrhaphy was performed on 115 patients with a total of 120 hernias. Of these 58 patients with 60 hernias underwent the transabdominal preperitoneal patch repair (TAPP) without plug and 57 patients with a total of 60 hernias were offered the extraperitoneal (EXTRA) approach using a distension balloon. The average operative time was 55 min for the TAPP and 50 min for the EXTRA procedure. The overall recurrence rate was 1.7% with a follow up of 1-27 months. The recurrence rate was 3.4% for the TAPP and none for the EXTRA approach. All patients returned to their normal activity within 1 week of discharge. Patients undergoing the EXTRA repair consumed less amount of narcotic analgesic than did the group undergoing the TAPP repair. Of the EXTRA group 58% did not require any analgesic, compared to 22% of the TAPP group (p < 05). There were no intraoperative complications. A total of 8 (6.9%) postoperative complications occurred in 115 patients. Four complications (6.9%) occurred in the TAPP procedure: 2 transient urinary retentions, 1 pulmonary edema, and 1 Richter's type hernia. Four (6.9%) complications occurred in the EXTRA procedure: 1 urinary retention, 2 abdominal wall ecchymoses, and 1 thoracic pain. Hospital stay was shorter for the EXTRA group: 57% were discharged the same day and 98% were discharged within 24 h of their operations for the EXTRA group compared to 10 and 84%, respectively, for the TAPP (p < 0.05). Laparoscopic extraperitoneal hernia repair can be accomplished with shorter hospitalization and less analgesic requirement than the TAPP repair. The overall incidence of complications, the recurrence rate, and the return to normal activity were not different between the two types of repair.

Hypercalcemia in Langerhans' cell granulomatosis with elevated 1,25 dihydroxyvitamin D (calcitriol) level

A 48-year-old woman presented with a history of premature menopause, polyuria, polydipsia, fever, and diffuse bony tenderness. Her evaluation revealed central diabetes insipidus, hypothalamic amenorrhea, an elevated free calcium on multiple occasions with an elevated 1,25 dihydroxyvitamin D level, and osteoporosis by densitometry. Skeletal series revealed multiple lytic lesions involving the long bones. The diagnosis of Langerhans' cell granulomatosis was made. She was treated with hormone replacement therapy, radiotherapy, and vinblastine, with a dramatic improvement in her pain and a near normalization of her free calcium. Whereas hypercalcemia has been described in several granulomatous disorders and is secondary to unregulated extrarenal production of 1,25 dihydroxyvitamin D, it is, however, extremely rare in Langerhans' cell granulomatosis. This is the first case report of Langerhans' cell granulomatosis with hypercalcemia and documented elevated increased 1,25 dihydroxyvitamin D level that responded to the treatment of her primary disease.

Dissolution rate studies from a stationary disk/rotating fluid system

The dissolution rates for hydrocortisone alcohol and acetate were determined using a stationary disk/rotating fluid system. The hydrocortisone was compressed in a tablet die, and the die placed in a vessel above a rotating magnetic bar. Dissolution rates were evaluated in aqueous media under conditions involving the following independent variables: solubility (Cs), diffusion coefficient (D), viscosity (v), rotational speed (omega), and tablet radius (r). A design equation which relates dissolution rate (R) to these variables was formulated for the system R alpha Cs D2/3 (v) -1/6(omega)1/2(r)3/2 This design equation adequately represents the system, which is related to fluid mechanics and convective diffusion models. The fluid mechanics model assumes that the fluid ideally rotates as solid-body rotation and the momentum layer is initiated at the outside radius of the tablet die. The convective diffusion model is based on the formation of a diffusion layer at the outside radius of the dissolving surface and a predictable relationship between the momentum and the mass transport quantities of bulk viscosity and diffusion coefficient. This configuration, like the rotating disk in a stationary fluid, offers the attractive attribute of being useful to study drug release mechanisms for systems of pharmaceutical interest.

Hyperphosphatemic familial tumoral calcinosis secondary to fibroblast growth factor 23 (FGF23) mutation: a report of two affected families and review of the literature

Hyperphosphatemic familial tumoral calcinosis (HFTC), secondary to fibroblast growth factor 23 (FGF23) gene mutation, is a rare genetic disorder characterized by recurrent calcified masses. We describe young Lebanese cousins presenting with HFTC, based on a retrospective chart review and a prospective case study. In addition, we present a comprehensive review on the topic, based on a literature search conducted in PubMed and Google Scholar, in 2014 and updated in December 2017. While the patients had the same previously reported FGF23 gene mutation (homozygous c.G367T variant in exon 3 leading to a missense mutation), they presented with variable severity and age of disease onset (at 4 years in patient 1 and at 23 years in patient 2). A review of the literature revealed several potential patho-physiologic pathways of HFTC clinical manifestations, some of which may be independent of hyperphosphatemia. Most available treatment options aim at reducing serum phosphate level, by stimulating renal excretion or by inhibiting intestinal absorption. HFTC is a challenging disease. While the available medical treatment has a limited and inconsistent effect on disease symptomatology, surgical resection of calcified masses remains the last resort. Research is needed to determine the safety and efficacy of FGF23 replacement or molecular therapy, targeting the specific genetic aberration. Hyperphosphatemic familial tumoral calcinosis is a rare genetic disorder characterized by recurrent calcified masses, in addition to other visceral, skeletal, and vascular manifestations. It remains a very challenging disease.

Hemorrhagic transformation after stroke: inter- and intrarater agreement

BACKGROUND AND PURPOSE

Hemorrhagic transformation (HT) is a complication of stroke that can occur spontaneously or after treatment. We aimed to assess the inter- and intrarater reliability of HT diagnosis.

METHODS

Studies assessing the reliability of the European Cooperative Acute Stroke Study (ECASS) classification of HT or of the presence (yes/no) of HT were systematically reviewed. A total of 18 raters independently examined 30 post-thrombectomy computed tomography scans selected from the Aspiration versus STEnt-Retriever (ASTER) trial. They were asked whether there was HT (yes/no), what the ECASS classification of the particular scan (0/HI1/HI2/PH1/PH2) (HI indicates hemorrhagic infarctions and PH indicates parenchymal hematomas) was and whether they would prescribe an antiplatelet agent if it was otherwise indicated. Agreement was measured with Fleiss' and Cohen's κ statistics.

RESULTS

The systematic review yielded four studies involving few (≤3) raters with heterogeneous results. In our 18-rater study, agreement for the presence of HT was moderate [κ = 0.55; 95% confidence interval (CI), 0.41-0.68]. Agreement for ECASS classification was only fair for all five categories, but agreement improved to substantial (κ = 0.72; 95% CI, 0.69-0.75) after dichotomizing the ECASS classification into 0/HI1/HI2/PH1 versus PH2. The inter-rater agreement for the decision to reintroduce antiplatelet therapy was moderate for all raters, but substantial among vascular neurologists (κ = 0.70; 95% CI, 0.57-0.84).

CONCLUSION

The ECASS classification may involve too many categories and the diagnosis of HT may not be easily replicable, except in the presence of a large parenchymal hematoma.

Evaluation of a tube method for determining diffusion coefficients for sparingly soluble drugs

Evaluation of a non-steady state method using glass tubes for the determination of diffusion coefficients is the purpose of this study. Unlike capillaries, glass tubes accommodate a larger volume of solution, facilitating assay procedures. Tubes are more susceptible to convection than are capillaries, but this effect is anticipated and accounted for in experimental design and data treatment. Glass tubes, 66 or 90 mm in length and 2 mm outer diameter, were siliconized and then filled with aqueous drug solution and placed in a jacketed flask containing gently stirred solvent at 25 degrees C. Diffusion experiments were run from 140 to 168 hours. At the end of this time period, the tubes were removed from the flask, placed in an ultrasonic vibrator for one minute, and their contents assayed spectrophotometrically. Data collected using potassium chloride as the diffusant showed little tube-to-tube variability, demonstrating the precision of the tube method, while diffusion coefficients determined for benzoic acid and p-aminobenzoic acid using the tube method tested the accuracy of the method by comparing reasonably well with values obtained using standard methods such as the rotating disk, free boundary, and membrane cell. Experiments done with either hydrocortisone or sulfisoxazole as the diffusant demonstrated the appropriateness of the tube method for the study of the diffusion of sparingly soluble pharmaceutical solutes.

Frequency of the CCR5-delta 32 chemokine receptor gene mutation in the Lebanese population

A direct correlation between HIV infection and mutation in the chemokine receptor [CCR5] gene has been established. However, such correlation has never been investigated in Lebanon. We report the frequency of the CCR5-delta 32 mutation in a r and om sample of 209 healthy, HIV-1 seronegative Lebanese aged 19-68. Overall, 4.8% were heterozygous for the mutation. Homozygosity was absent from our sample. The frequency for the CCR5-delta 32 allele was 2.5%. Distribution of the mutation was unaffected by sex, age, religion or educational level. The frequency in the Lebanese population is consistent with that in the origin of the mutation in northern Europe. This could be attributed to a gene flow into the Middle East from northern Europe

Coeliac disease presenting as severe hypoglycaemia in youth with type 1 diabetes

BACKGROUND

Coeliac disease is an autoimmune disorder classically characterized by gastrointestinal symptoms and poor growth. The disease can be difficult to recognize in patients with Type 1 diabetes mellitus. Some clinicians find treatment of the disease in asymptomatic individuals controversial.

CASE REPORTS

Two adolescent female patients with Type 1 diabetes experienced recurrent hypoglycaemic seizures. Neither patient reported gastrointestinal symptoms or poor growth. After diagnosis and treatment of coeliac disease, hypoglycaemia resolved.

CONCLUSION

These cases illustrate how frequent unexplained severe hypoglycaemia can be an atypical presentation of coeliac disease in youth with Type 1 diabetes. Furthermore, they emphasize the importance of screening and treatment of coeliac disease in asymptomatic patients with Type 1 diabetes. Although controversial, management of coeliac disease in these asymptomatic patients can prevent the vicious cycle of recurrent hypoglycaemia and decrease risk for morbidity and death.

Renal extraction of glutamine from plasma and whole blood: studies in dogs and rats

The change in plasma and blood cell pools of L-glutamine during a single pass through the kidney was studied in dogs and rats. It was shown that the glutamine content of blood cells does not change following one passage through the renal vascular bed in normal or acidotic dogs. Furthermore, an infusion of L-glutamine elevating by 10-fold the plasma concentration of this amino acid only minimally changed the blood cells' glutamine content. Therefore within the time frame of acute experiments, the dog blood cells can be assumed to be impermeable to glutamine in vivo. Accordingly, renal glutamine extraction can be measured using either whole blood or plasma arteriovenous difference in this species. However, the latter value is larger and therefore can be measured more accurately. In normal rats, no net renal glutamine extraction is measured. In contrast, a considerable renal glutamine uptake occurs in acidotic rats, 23% of the extracted glutamine coming from the blood cell pool. A load of glutamine in vivo significantly elevates both the plasma and the blood cell concentration. It is concluded (i) that the renal extraction of glutamine is best estimated using plasma arteriovenous difference in the dog, especially when the renal extraction is small; (ii) that whole blood measurements should be obtained in the rat.