Alpha herpesvirus exocytosis from neuron cell bodies uses constitutive secretory mechanisms, and egress and spread from axons is independent of neuronal firing activity

Alpha herpesviruses naturally infect the peripheral nervous system, and can spread to the central nervous system, causing severe debilitating or deadly disease. Because alpha herpesviruses spread along synaptic circuits, and infected neurons exhibit altered electrophysiology and increased spontaneous activity, we hypothesized that alpha herpesviruses use activity-dependent synaptic vesicle-like regulated secretory mechanisms for egress and spread from neurons. Using live-cell fluorescence microscopy, we show that Pseudorabies Virus (PRV) particles use the constitutive Rab6 post-Golgi secretory pathway to exit from the cell body of primary neurons, independent of local calcium signaling. Some PRV particles colocalize with Rab6 in the proximal axon, but we did not detect colocalization/co-transport in the distal axon. Thus, the specific secretory mechanisms used for viral egress from axons remains unclear. To address the role of neuronal activity more generally, we used a compartmentalized neuron culture system to measure the egress and spread of PRV from axons, and pharmacological and optogenetics approaches to modulate neuronal activity. Using tetrodotoxin to silence neuronal activity, we observed no inhibition, and using potassium chloride or optogenetics to elevate neuronal activity, we also show no increase in virus spread from axons. We conclude that PRV egress from neurons uses constitutive secretory mechanisms: generally, activity-independent mechanisms in axons, and specifically, the constitutive Rab6 post-Golgi secretory pathway in cell bodies.

Viral infections and pathogenesis of glaucoma: a comprehensive review

Glaucoma is a leading cause of irreversible blindness worldwide, caused by the gradual degeneration of retinal ganglion cells and their axons. While glaucoma is primarily considered a genetic and age-related disease, some inflammatory conditions, such as uveitis and viral-induced anterior segment inflammation, cause secondary or uveitic glaucoma. Viruses are predominant ocular pathogens and can impose both acute and chronic pathological insults to the human eye. Many viruses, including herpes simplex virus, varicella-zoster virus, cytomegalovirus, rubella virus, dengue virus, chikungunya virus, Ebola virus, and, more recently, Zika virus (ZIKV) and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), have been associated with sequela of either primary or secondary glaucoma. Epidemiological and clinical studies suggest the association between these viruses and subsequent glaucoma development. Despite this, the ocular manifestation and sequela of viral infections are not well understood. In fact, the association of viruses with glaucoma is considered relatively uncommon in part due to underreporting and/or lack of long-term follow-up studies. In recent years, literature on the pathological spectrum of emerging viral infections, such as ZIKV and SARS-CoV-2, has strengthened this proposition and renewed research activity in this area. Clinical studies from endemic regions as well as laboratory and preclinical investigations demonstrate a strong link between an infectious trigger and development of glaucomatous pathology. In this article, we review the current understanding of the field with a particular focus on viruses and their association with the pathogenesis of glaucoma.

20 years outcomes after hybrid coronary revascularization

Background

Hybrid coronary revascularization (HCR) is a Heart Team directed strategy for selected patients with mutlivessel coronary artery disease. However, data on long-term results are lacking.

Purpose

To analyse long-term outcomes after HCR over a 20-year period.

Methods

Between 1996 and 2020, a total of 2667 consecutive patients underwent minimally invasive direct coronary artery bypass grafting (MIDCAB) at our institution, and 177 of these were planned HCR cases. Planned HCR consisted of a MIDCAB procedure to the left anterior descending (LAD) artery preceded or followed by percutaneous intervention (PCI) of non-LAD lesions. We excluded patients who underwent prior cardiac surgery and patients with emergency indications for revascularization (either surgical or transcatheter). Short- and long-term results for the entire cohort were analysed and a propensity score-matched comparison was performed between MIDCAB-first and PCI-first revascularization strategies.

Results

The mean age of all patients was 67 (±12) years with 37% suffering from diabetes (n=67). The median time-interval between MIDCAB and PCI was 22 days (IQR 5–53). Thirty-day mortality was 3.9% for the entire cohort. A total of 9 patients (5.0%) underwent early target vessel revascularization; 4 patients (2.2%) involving the LAD following the MIDCAB procedure and 5 patients (2.8%) involving non-LAD vessels following PCI. The rate of incomplete revascularization following completion of HCR was 25.4% (n=45). Long-term survival was 53.5% at 15 years and 30.4% at 20 years and the rate of repeat revascularization with PCI or surgery was 15.8% (n=28). The propensity matched sub-analysis of MIDCAB- versus PCI-first strategy showed no significant differences with regard to short- and long-term outcomes. Age (HR: 1.01, 95% CI 0.98–1.04, p=0.042) and incomplete revascularization (HR: 2.60, 95% CI 1.26–5.34; p=0.01) were independent risk factors for follow-up mortality.

Conclusions

Hybrid coronary revascularization as a less invasive strategy for selected patients is associated with acceptable 20-year survival. However, repeat revascularization rates are substantial.

Funding Acknowledgement

Type of funding sources: None.

Minimally invasive ventricular assist device implantation

Durable mechanical circulatory support (MCS) systems are established therapy option in patients with end-stage heart failure, with increasing importance during the last years due to donor organ shortage. Left ventricular assist devices (LVADs) are traditionally implanted through median sternotomy (MS). However, improvement in the pump designs during the last years led to evolvement of new surgical approaches that aim to reduce the invasiveness of the procedure. Numerous reports and studies have shown the viability and possible advantages of less-invasive approach compared to the sternotomy approach. The less invasive implant strategies for LVADs, while vague in definition, are characterized by minimizing surgical trauma and if possible, cardio-pulmonary bypass related complications. Usually it involves minimizing or completely avoiding sternal trauma, avoiding heart luxation while simultaneously leaving the major part of pericardium intact. There is no consensus between the centers regarding the ideal approach for LVAD implantation. Some centers, like our center, perform by default VAD implantation using less invasive approach in almost all patients and some centers use only sternotomy approach. The aim of this review article is to shed light on the currently available less invasive options of LVAD implantation, with particular focus on the centrifugal pumps, and their possible advantages compared to traditional sternotomy approach.

The nuclear matrix elements of 0νββ decay and the NUMEN project at INFN-LNS

The goal of NUMEN project is to access experimentally driven information on Nuclear Matrix Elements (NME) involved in the neutrinoless double beta decay (0νββ), by high-accuracy measurements of the cross sections of Heavy Ion (HI) induced Double Charge Exchange (DCE) reactions. The knowledge of the nuclear matrix elements is crucial to infer the neutrino average masses from the possible measurement of the half-life of 00νββ decay and to compare experiments on different isotopes. In particular, the (18O, 18Ne) and (20Ne, 20O) reactions are performed as tools for β+β+ and β-β- decays, respectively. The experiments are performed at INFN - Laboratory Nazionali del Sud (LNS) in Catania using the Superconducting Cyclotron (CS) to accelerate the beams and the MAGNEX magnetic spectrometer to detect the reaction products. The measured cross sections are very low, limiting the present exploration to few selected isotopes of interest in the context of typically low-yield experimental runs. In order to make feasible a systematic study of all the candidate nuclei, a major upgrade of the LNS facility is foreseen to increase the experimental yield of about two orders of magnitude. To this purpose, frontier technologies are going to be developed for both the accelerator and the detection systems. In parallel, advanced theoretical models will be developed to extract the nuclear structure information from the measured cross sections.

Brain SPECT scans in students with specific learning disability: Preliminary results

Background and Objectives:

Brain single-photon emission computed tomography (SPECT) assesses brain function through measurement of regional cerebral blood flow. This study was conducted to assess whether students with newly diagnosed specific learning disability (SpLD) show any abnormalities in cerebral cortex perfusion.

Settings and Design:

Cross-sectional single-arm pilot study in two tertiary care hospitals.

Subjects and Methods:

Nine students with SpLD were enrolled. Brain SPECT scan was done twice in each student. For the first or “baseline“ scan, the student was first made to sit with eyes open in a quiet, dimly lit room for a period of 30–40 min and then injected intravenously with 20 mCi of 99mTc-ECD. An hour later, “baseline scan“ was conducted. After a minimum gap of 4 days, a second or “test scan“ was conducted, wherein the student performed an age-appropriate curriculum-based test for a period of 30–40 min to activate the areas in central nervous system related to learning before being injected with 20 mCi of 99mTc-ECD.

Statistical Analysis Used:

Cerebral cortex perfusion at rest and after activation in each student was compared qualitatively by visual analysis and quantitatively using NeuroGam™ software.

Results:

Visual analysis showed reduction in regional blood flow in temporoparietal areas in both “baseline“ and “test“ scans. However, when normalization was attempted and comparison done by Talairach analysis using NeuroGam software, no statistically significant change in regional perfusion in temporoparietal areas was appreciated.

Conclusion:

Brain SPECT scan may serve as a robust tool to identify changes in regional brain perfusion in students with SpLD.

Gallbladder perforation in acute acalculous cholecystitis: an atypical manifestation of dengue fever

Among the atypical manifestations of dengue fever, comprising 15.8% of all cases, acalculous cholecystitis forms a small subset. Acalculous cholecystitis is managed conservatively in majority of cases and a chance of gall bladder perforation is low (2-18%). Management of gall bladder perforation in the scenario of Dengue is sometimes complicated by presence of thrombocytopenia and its complications thereof. Mortality associated with gall bladder perforation is relatively high. Gallbladder usually perforates at the fundus and is to be dealt with surgically if it doesn’t localize. Laparoscopic management of gall bladder perforation is feasible as calot’s is relatively virgin (as there is no calculous disease). Thorough peritoneal toileting is possible and a chance of intra-abdominal abscess in post-operative period is a mere speculation. Laparoscopic management results in early recovery and fewer wound complications and lesser hospital stay.   

Carotid Endarterectomy in Patients with Renal Insufficiency: Should Selection Criteria be Different in Patients with Renal Insufficiency?

The objective of this study was to elucidate the relationship between outcomes from carotid endarterectomy (CEA) in patients with and without renal insufficiency.

Carotid endarterectomy is one of the most commonly performed vascular procedures. The role of cardiac comorbidity in carotid endarterectomy has been extensively studied. The relationship between renal failure and surgical outcomes has also been studied for both coronary artery bypass grafting and lower extremity occlusive disease. However, the role of renal insufficiency in relationship to decision making regarding surgical intervention for carotid stenosis is not well defined. The authors hypothesized that the outcomes from CEA were negatively influenced by renal dysfunction. A retrospective review was made of consecutive CEAs performed at their institution from 1990 to 1995. Patients were grouped into 2 categories according to their renal function. Group A, 448 patients (90%) with creatinine level 1.8 mg/dL or less, and group B, 49 patients (10%) with creatinine levels more than 1.8 mg/dL. Data from patients on dialysis are presented but were excluded for the purpose of analysis.

Included in the study were 497 patients with a mean age of 70 +8.9 and 74 +8.9 for groups A and B, respectively. Preoperative creatinine was 1.1 (±0.25) mg/dL for group A and 2.5 (+0.81) mg/dL for group B. Outcomes were as follows: perioperative cardiac events 5.4% vs 28.6%, stroke rates 2.7% vs 2.0%, and mortality rates 0.9% vs 8.2%, for groups A and B, respectively. At 60-month follow-up the stroke rates were 7.6% vs 6.1%, and the mortality rates 22.8% vs 59.2%, for groups A and B, respectively.

While patients with chronic renal insufficiency have no increased risk of perioperative or long-term neurologic events, perioperative and long-term mortality rates are significantly increased. This significant reduction in survival should prompt a more cautious application of CEA in patients with increased creatinine.

Mapping a complete neural population in the retina

Recording simultaneously from essentially all of the relevant neurons in a local circuit is crucial to understand how they collectively represent information. Here we show that the combination of a large, dense multielectrode array and a novel, mostly automated spike-sorting algorithm allowed us to record simultaneously from a highly overlapping population of >200 ganglion cells in the salamander retina. By combining these methods with labeling and imaging, we showed that up to 95% of the ganglion cells over the area of the array were recorded. By measuring the coverage of visual space by the receptive fields of the recorded cells, we concluded that our technique captured a neural population that forms an essentially complete representation of a region of visual space. This completeness allowed us to determine the spatial layout of different cell types as well as identify a novel group of ganglion cells that responded reliably to a set of naturalistic and artificial stimuli but had no measurable receptive field. Thus, our method allows unprecedented access to the complete neural representation of visual information, a crucial step for the understanding of population coding in sensory systems.

Piezoelectric nanoribbons for monitoring cellular deformations

Methods for probing mechanical responses of mammalian cells to electrical excitations can improve our understanding of cellular physiology and function. The electrical response of neuronal cells to applied voltages has been studied in detail, but less is known about their mechanical response to electrical excitations. Studies using atomic force microscopes (AFMs) have shown that mammalian cells exhibit voltage-induced mechanical deflections at nanometre scales, but AFM measurements can be invasive and difficult to multiplex. Here we show that mechanical deformations of neuronal cells in response to electrical excitations can be measured using piezoelectric PbZr(x)Ti(1-x)O(3) (PZT) nanoribbons, and we find that cells deflect by 1 nm when 120 mV is applied to the cell membrane. The measured cellular forces agree with a theoretical model in which depolarization caused by an applied voltage induces a change in membrane tension, which results in the cell altering its radius so that the pressure remains constant across the membrane. We also transfer arrays of PZT nanoribbons onto a silicone elastomer and measure mechanical deformations on a cow lung that mimics respiration. The PZT nanoribbons offer a minimally invasive and scalable platform for electromechanical biosensing.

Diverting loop colostomy for the treatment of refractory gastrointestinal bleeding secondary to radiation proctitis

Chronic radiation proctitis is an uncommon and serious complication of radiotherapy for pelvic malignancies. It has been suggested that fecal stream diversion decreases bowel irritation, resulting in decreased rectal bleeding. We report on the outcome of patients after a diverting loop colostomy for the treatment of severe radiation proctitis. All consecutive patients with chronic proctitis treated with diverting loop colostomy for bleeding at one institution between October 1991 and June 1999 were studied. Four patients presented with rectal bleeding and diarrhea, and two patients had only bleeding. The mean dose of radiation received was 6,115.11 +/- 955.11 rad. Symptoms of chronic proctitis appeared at varying intervals of time after radiation, ranging from 14 months to 17 years. There were no operative complications. During follow-up (36 +/- 29 months), only one of nine patient continued to bleed. Four patients died during the study (cancer relapse, two patients; heart failure, one patient; one death was caused by severe radiation proctitis). Diverting sigmoid loop colostomy, when performed in properly selected patients with severe bleeding secondary to radiation proctitis refractory to medical management, is well tolerated and effective.

Surgical technique for inferior mesenteric vein to renal vein shunt in portal hypertension

An important role still exists for the creation of surgical portasystemic shunts. Multiple techniques have been described. However, no particular one is satisfactory for all clinical situations. The objective of the present paper is to describe an alternative surgical technique for the creation of a decompressive portasystemic shunt. This technique consists of an end-to-side anastomosis between the inferior mesenteric vein and the left renal vein. In our experience, the inferior mesenteric vein to left renal vein anastomosis may be a useful portal decompressive shunt for patients with otherwise difficult peri-portal or peri-pancreatic anatomic exposures. This technique should be a useful tool in the armamentarium of surgeons dealing with patients who need portal decompressive surgical shunts.

SAPHO syndrome: 20-year follow-up

Considerable attention has been paid in the past 10 years to the radiological spectrum of disease entities belonging to the SAPHO syndrome. We report an unusual case presenting with an extra-axial (femoral) lesion, prior to description of this syndrome, which was radiologically and histologically mistaken for a parosteal osteosarcoma. Nineteen years later, a further lesion developed in the scapula together with the typical sternoclavicular manifestations, at which stage the correct diagnosis of SAPHO syndrome was established.

A comparison of 5-minute povidone-iodine scrub and 1-minute povidone-iodine scrub followed by alcohol foam

The purpose of this study was to determine if a 1-minute scrub with povidone-iodine followed by alcohol foam is as effective as a 5-minute scrub with povidone-iodine in reducing skin bacterial counts. A 1-minute scrub with povidone-iodine followed by alcohol foam and a 5-minute scrub with povidone-iodine was done. In the first study, cultures were obtained after 1 hour, and in the second study, cultures were obtained after 2 hours. Cultures were obtained by imprinting the first, second, and third fingers on nutrient agar plates. Bacterial counts were then obtained at 24 and 48 hours. The study involved two groups of 12 participants and a total of 37 patients over a period of 5 months. The results show that there was no significant difference between the number of colonies cultured for the 1-minute scrub compared with the 5-minute scrub for either the 1-hour or the 2-hour study. In fact, the total number of bacterial colonies was less after the 1-minute scrub with alcohol foam than after the standard 5-minute scrub in both the 1-hour group (10 vs. 18) and the 2-hour group (18 vs. 44).

Differential expression of acidic and basic fibroblast growth factors in benign prostatic hyperplasia identified by immunohistochemistry

OBJECTIVE

To detect the expression and to determine the relative cellular locations of the two peptide growth factors, acidic fibroblast growth factor (a-FGF) and basic (b)-FGF in tissues from human benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A series of 50 sequential and unselected cases of human BPH tissues, obtained after transurethral prostatectomy, was examined. Adjacent sections of formalin-fixed and paraffin wax-embedded tissues were stained immunohistochemically for expression of a-FGF and b-FGF using well-characterized and commercially available antibodies. The stained tissue sections were assessed for the cellular distribution of immunohistochemical products and analysed according to the relative intensity of staining as well as the spatial relationships of positively stained cells.

RESULTS

Acidic-FGF was weakly expressed with a pancytoplasmic distribution within luminal glandular epithelial cells in regions of prostatic intra-epithelial neoplasia (both PIN I and II) but not by non-dysplastic normal or hyperplastic tissues. No expression of a-FGF was detected in basal epithelial cells or in the stromal compartment of any tissue examined. In contrast, b-FGF was strongly expressed within the cytoplasm of all basal epithelial cells, but not by luminal epithelial cells, in morphologically normal regions of all cases examined. Basal expression of b-FGF was diminished, or absent, in regions of mild epithelial dysplasia, particularly those strongly expressing a-FGF. Extensive nuclear and cytoplasmic expression of b-FGF occurred predominantly in smooth muscle-type stromal cells but not in all types of stromal cells.

CONCLUSIONS

This study confirmed both a differential and a reciprocal expression of a- and b-FGF in non-dysplastic prostatic hyperplasia and in mildly dysplastic regions of prostatic tissues. While only small amounts of a-FGF were expressed in BPH, exclusively in the luminal epithelial compartment, its consistent appearance in PIN I and II suggests that it might contribute to the early stages of PIN. Conversely, b-FGF may be an important mediator of stromal-epithelial interaction during the pathogenesis of BPH. These results provide new information about the relative expression of these growth factors, particularly in the architectural relationships between different cell-types within normal and non-malignant prostatic tissues.

Delay in improvement of ankle-arm index and ankle waveforms after lower-extremity revascularization

Ankle-arm index (AAI) and pulse volume recording (PVR) are commonly used in the early postoperative period to measure the outcome after lower-extremity revascularization. They are also used in addition to duplex scan for long-term follow-up of these patients. We noticed that in some patients the AAI and/or PVR after revascularization procedures did not improve immediately after surgery, but took 24 hours or longer to do so. We retrospectively reviewed the records of 47 patients who underwent various lower-extremity revascularization procedures and found that out of 20 patients who had AAI and/or PVR measured in the recovery room, 8 patients took 24 hours and 1 patient took more than 24 hours for maximal improvement of their AAI and/or PVR. This may be related to vascular spasm, and knowledge of this delayed improvement is important in preventing errors during follow-up.

Occult inguinal hernia, a cause of rapid onset of penile and scrotal edema in patients on chronic peritoneal dialysis

From 1976 to 1993 we inserted 160 chronic peritoneal dialysis catheters for renal failure patients. Three of these patients developed sudden onset of penile and scrotal edema after the catheter had been in place for several months. The first patient was diagnosed by instilling technetium sulfur colloid in the peritoneal cavity, which showed the radioisotope flowing via the right inguinal canal. He was operated on and the processus vaginalis was tied off and the scrotal and penile edema resolved. Subsequently, two more patients were seen with similar problems and had their inguinal canals explored and the processus vaginalis in one and the hernia sac in the other were found and tied off, which resulted in resolution of the problem. This is an uncommon complication, reported to occur in 3 to 4% of patients.

Thrombosis of tibial arteries in a patient receiving tamoxifen therapy

BACKGROUND

Tamoxifen has been used extensively as adjuvant therapy in the treatment of pre- and post-menopausal patients with breast cancer. One of its known complications is venous thromboembolism. However, arterial thrombosis has been reported rarely.

METHODS

A 49-year-old patient with breast cancer had had a total mastectomy 3 years earlier. She was receiving tamoxifen therapy when she developed a sudden onset of pain and numbness of the left foot and calf. An arteriogram showed thrombosis of her tibial arteries.

RESULTS

This thrombosis was lysed successfully with urokinase therapy, and tamoxifen therapy was discontinued. At follow-up 4 months later, the patient had normal circulation to both legs.

CONCLUSIONS

Patients receiving tamoxifen should be monitored closely for the development of venous or arterial thromboembolism.

Paraganglioma of the vagus nerve masquerading as a carotid body tumor

A case of paraganglioma of the vagus nerve in a 69-year-old woman presented as a pulsatile neck mass of 20 years duration. Angiogram showed it to be a vascular tumor and suggested the diagnosis of carotid body tumor. At operation, the tumor was found to involve the vagus nerve, which needed to be resected. The relevant literature regarding paragangliomas of the vagus nerve is discussed.

Venous ulceration of the hand secondary to a cimino fistula

Cimino fistula is an anastomosis created for chronic hemodialysis, between the radial artery and cephalic vein near the wrist. Its complications include thrombosis (most frequent), infection, congestive heart failure, arterial insufficiency, venous hypertension, vascular access neuropathy, and aneurysms. Of these, venous hypertension appears to occur rarely. We report here a case where it resulted in pigmentation, swelling, and ulceration of the middle finger. It was surgically treated, without ligating the arteriovenous fistula, by selective ligation of tributaries from the affected fingers.

Familial acalculous gallbladder disease

Four patients, all sisters, presented a long-standing history of pain in the gallbladder region and no calculi. All were first thoroughly investigated and then relieved of their symptoms by cholecystectomy. This prompted an investigation of their family over three generations, which revealed a surprisingly large number of relatives, mostly female, with acalculous gallbladder disease. Our review of various syndromes causing pain in the gallbladder region, including biliary dyskinesia, cystic duct syndrome, and chronic acalculous cholecystitis, makes a case for the existence of familial incidence of noncalculous and calculous gallbladder disease, possibly related to the disturbance of the autonomic nervous system affecting emptying of the gallbladder.

High-grade immature teratoma of the testis in infancy

Teratomas of the testis in infants are rare tumors which often display immature elements, disturbing in their histologic appearance. Although the presence of similar histologic features worsens prognosis in testicular teratomas in adults and in teratomas of infants and children presenting at other anatomic sites, the presence of immature elements in testicular teratomas of infancy does not appear to affect prognosis. Therefore, orchiectomy alone is adequate therapy for these neoplasms. The case of an 8-month-old infant with a teratoma of testis is presented.

The medical care of Iraqi enemy prisoners of war

During Operation Desert Storm, Approximately 62,000 enemy prisoners of war (EPWs) were captured by allied forces. Most of these EPWs were taken during the ground war and the weeks following. Over 20,000 of these were interned at East Camp, which was located approximately 125 miles south of the Kuwaiti border. The 300th Field Hospital was tasked to provide inpatient and outpatient care to the EPWs. This paper summarizes the experience, analyzing the diseases encountered, the types of medicines needed, and the unique problems of treating non-English speaking EPWs. From January 27 to February 23, 1991, approximately 308 patients were treated. From the beginning of the ground war on February 24, through March 30, approximately 8,979 patients were treated. The most common condition seen was dental disease (24.0%). Other commonly treated conditions were upper respiratory infection (12.4%), headache (11.7%), and urinary tract infections (9.6%). The unique problems of language barriers and security requirements increased the difficulty and the time required to conduct sick call for Iraqi EPWs.

Using a saphenous vein branch for a patch

The majority of vascular surgeons find that the autologous saphenous vein is the conduit of choice for femoropopliteal and femorotibial bypasses. The branches of the saphenous vein are eventually ligated but can serve several useful purposes, such as completing an angiogram, passing a valvulotome, or widening the anastomosis. Another use for the branches consists of using the branch as a patch when the vein needs to be reopened, i.e., for thrombectomy, during the postoperative period. This is done by making a venotomy adjacent to a branch. The surgical technique, as practiced by us, is described and illustrated by a schematic diagram.

Surgical treatment of pilonidal disease: comparison of three different methods in fifty-nine cases

The surgical treatment of pilonidal disease at the Robert Packer Hospital from 1983 to 1989 was reviewed. During that period, 59 patients were operated on for definitive treatment of the disease. The different methods of treatment, namely excision and packing (28 cases), marsupialization (11 cases), and excision and primary closure (20 cases) were compared in terms of age and sex distribution, length of hospital stay, number of post-operative visits, time required for complete healing, complications, and recurrence rate. The operations were performed by surgical residents under the supervision of board-certified surgeons. The average time for complete healing was 21 weeks, 8 weeks, and 3 weeks, respectively, for the different methods. Recurrence rates were essentially nil for all methods. It was concluded that excision and primary closure is the superior method in the treatment of pilonidal disease. The relevant literature was reviewed and the surgical technique discussed.

Modified Kraske approach for disease of the mid-rectum

A modification of Dr. Paul Kraske's approach for removal of mid-rectal lesions has been used in 11 patients from 1977 to 1988 by the senior authors. Patients ranged in age from 56 to 89 yr, with an average of 67 yr. There were seven male and four female patients. Indications for surgery were as follows: villous adenoma (seven), carcinoid (one), recurrent dysplasia in a previous endoscopic polypectomy site (one), positive distal margin for neoplasm following low anterior sigmoid resection (one), and adenocarcinoma in one elderly poor-risk patient. All lesions were in the middle rectum (7-11 cm from the anal verge, average 9 cm). The postoperative stay ranged from 6 to 12 days with a mean of 8 days. The average follow-up for the 11 patients is 3 1/2 yr (1 month to 7 yr), with only one patient having a local recurrent lesion. There was no morbidity or mortality. We conclude that this modification of the Kraske approach offers a good alternative for excision of mid-rectal lesions in terms of technical ease, efficacy, safety, and patient tolerance. The modified Kraske approach is indicated in certain situations and should be a part of the surgeon's armamentarium.

Saphena varix: a case report

Saphena varix is a rare condition characterized by isolated distention of the saphenous vein immediately below the sapheno-femoral junction. The clinical significance of saphena varix lies in its differentiation from other conditions that cause a groin mass. A case of saphena varix is presented and methods for differentiating this unusual condition from other causes of groin masses are discussed.

Obturator hernia: a difficult diagnosis

We have presented the case of an elderly woman with severe kyphoscoliosis, osteoarthritis and left knee effusion who had symptoms and signs of intermittent intestinal obstruction. Operation showed a left-sided obturator hernia. In any elderly, debilitated, chronically ill woman, symptoms and signs of recurrent small-bowel obstruction (without a history of abdominal surgery or external hernias) and pain along the ipsilateral thigh and knee (Howship-Romberg sign) should raise suspicion for an obturator hernia. If the hernia is not palpable by physical examination, a CT scan of the pelvis and upper aspect of the thigh would confirm the diagnosis before operation and allow prompt treatment and better chance of patient survival.

The lack of effect of pentoxifylline on random skin flap survival

The effects of pentoxifylline on skin flap survival were studied in rabbits. A total of 40 rabbits had caudally based single-pedicle flaps measuring 4 x 14 cm raised on the mid dorsum of each animal. Twenty of these rabbits were given intraperitoneal injections of pentoxifylline in doses of 24 mg/kg per day beginning 48 hours prior to flap construction and continued daily for 7 days postoperatively. The remaining 20 control rabbits received intraperitoneal injections of saline in equal volumes as the experimental groups. At the end of 7 days, viable flap length was visually inspected and measured in all 40 rabbits. There was no significant difference in skin flap viability in rabbits treated with pentoxifylline compared to the control group.

Hypogastric artery aneurysm causing microscopic hematuria

Aneurysms of the hypogastric artery are rare. Most of the lesions are discovered incidentally but occasionally they produce urinary symptoms or rupture unexpectedly. We report a case of an isolated hypogastric artery aneurysm that caused painless microscopic hematuria. The natural history of these lesions and the surgical options are discussed briefly.

All-terrain vehicle injuries. A review at a rural level II trauma center

All-terrain vehicles (ATVs) have become a major source of morbidity and mortality with more than 600 deaths nationwide. Nearly half of those injured are children under 16 years. Twenty three ATV accidents were seen at the Guthrie Medical Center over a 30 month period ending in August 1986. Ten patients (43.5%) were under 16 years old. Of those injured who were older, alcohol was involved in 70 per cent of the accidents. Five accidents occurred on highways (21.7%), in spite of laws banning their use on public roads. Rollover type accidents and collisions were the most frequent mechanisms of injury (39% and 35%). Of 18 patients known not to have worn a helmet, 61 per cent sustained a closed head injury. In all, there were 88 injuries in 23 patients. Common injuries included lacerations (13), long bone fractures (13), renal contusions (11) and head injury (11). There were two deaths (8.7%), two cord transections with permanent disability, and a below-knee amputation. ATVs present a serious hazard to adult and children riders alike. Age limits, state licensing, safety programs, and protective equipment are all recommended as a means to reduce injury and death from recreational riding.

Actinomycosis at multiple colonic sites

A case of actinomycosis affecting multiple sites in the colon, masquerading as diverticulitis, is presented. Final diagnosis was delayed until a tuboovarian abscess developed that required resection and was found to contain sulfur granules. Bacteriology, pathophysiology, and antibiotic treatment of abdominal actinomycosis is discussed. Difficulties in diagnosis are mentioned.