Harvest site influences the growth properties of adipose derived stem cells.

The therapeutic potential of adult stem cells may become a relevant option in clinical care in the future. In hand and plastic surgery, cell therapy might be used to enhance nerve regeneration and help surgeons and clinicians to repair debilitating nerve injuries. Adipose-derived stem cells (ASCs) are found in abundant quantities and can be harvested with a low morbidity. In order to define the optimal fat harvest location and detect any potential differences in ASC proliferation properties, we compared biopsies from different anatomical sites (inguinal, flank, pericardiac, omentum, neck) in Sprague-Dawley rats. ASCs were expanded from each biopsy and a proliferation assay using different mitogenic factors, basic fibroblast growth factor (bFGF) and platelet-derived growth factor (PDGF) was performed. Our results show that when compared with the pericardiac region, cells isolated from the inguinal, flank, omental and neck regions grow significantly better in growth medium alone. bFGF significantly enhanced the growth rate of ASCs isolated from all regions except the omentum. PDGF had minimal effect on ASC proliferation rate but increases the growth of ASCs from the neck region. Analysis of all the data suggests that ASCs from the neck region may be the ideal stem cell sources for tissue engineering approaches for the regeneration of nervous tissue.

Hidradenitis suppurativa of the groin treated by radical excision and defect closure by medial thigh lift: aesthetic surgery meets reconstructive surgery.

INTRODUCTION: Hidradenitis suppurativa of the groin is a chronic, relapsing inflammatory disease of the skin and subcutaneous tissues. Radical surgical excision is the treatment of choice. Often split-skin grafting or wound healing by secondary intention are used for defect closure, sometimes with disfiguring results. We describe our experience with radical excision of localised inguinal hidradenitis suppurativa and immediate defect closure with a medial thigh lift. PATIENTS AND METHODS: Our hospital database was searched for all patients presenting to our institution for surgical treatment of hidradenitis suppurativa between 2001 and 2006. Only patients with hidradenitis confined to the groin were included. Exclusion criteria were simple abscess incisions, recurrence after previous grafting or flap surgery and extension of the disease outside the groin and presence of clinical signs of infection at the time of surgery. We documented patient demographics, sizes of defects, complications, time of follow-up, recurrences and patient satisfaction. RESULTS: A total of 8 patients with localised inguinal hidradenitis suppurativa were identified and 15 thigh lifts were performed. Defect size assessed on pathologic examination of the excised specimens averaged 15.9 cm x 4.3 cm x 1.3 cm (length x width x depth). All wounds but one healed primarily. Functional and aesthetic results were satisfactory. No major complications and no irritations of the genital area were observed. No recurrences were observed either. CONCLUSION: We propose the medial thigh lift to be considered for immediate defect closure after radical excision of localised inguinal hidradenitis suppurativa provided that no perifocal signs of infection are present after debridement.

Protective effect of intravitreal injection of vasoactive intestinal peptide-loaded liposomes on experimental autoimmune uveoretinitis.

PURPOSE: The aim of this study was to investigate the effect of a single intravitreal (i.v.t.) injection of vasoactive intestinal peptide (VIP) loaded in rhodamine-conjugated liposomes (VIP-Rh-Lip) on experimental autoimmune uveoretinitis (EAU). METHODS: An i.v.t. injection of VIP-Rh-Lip, saline, VIP, or empty-(E)-Rh-Lip was performed simultaneously, either 6 or 12 days after footpad immunization with retinal S-antigen in Lewis rats. Clinical and histologic scores were determined. Immunohistochemistry and cytokine quantification by multiplex enzyme-linked immunosorbent assay were performed in ocular tissues. Systemic immune response was determined at day 20 postimmunization by measuring proliferation and cytokine secretion of cells from inguinal lymph nodes (ILNs) draining the immunization site, specific delayed-type hypersensitivity (DTH), and the serum concentration of cytokines. Ocular and systemic biodistribution of VIP-Rh-Lip was studied in normal and EAU rats by immunofluorescence. RESULTS: The i.v.t. injection of VIP-Rh-Lip performed during the afferent, but not the efferent, phase of the disease reduced clinical EAU and protected against retinal damage. No effect was observed after saline, E-Rh-Lip, or VIP injection. VIP-Rh-Lip and VIP were detected in intraocular macrophages and in lymphoid organs. In VIP-Rh-Lip-treated eyes, macrophages expressed transforming growth factor-beta2, low levels of major histocompatibility complex class II, and nitric oxide synthase-2. T-cells showed activated caspase-3 with the preservation of photoreceptors. Intraocular levels of interleukin (IL)-2, interferon-gamma (IFN-gamma), IL-17, IL-4, GRO/KC, and CCL5 were reduced with increased IL-13. At the systemic level, treatment reduced retinal soluble autoantigen lymphocyte proliferation, decreased IL-2, and increased IL-10 in ILN cells, and diminished specific DTH and serum concentration of IL-12 and IFN-gamma. CONCLUSIONS: An i.v.t. injection of VIP-Rh-Lip, performed during the afferent stage of immune response, reduced EAU pathology through the immunomodulation of intraocular macrophages and deviant stimulation of T-cells in ILN. Thus, the encapsulation of VIP within liposomes appears as an effective strategy to deliver VIP into the eye and is an efficient means of the prevention of EAU severity.

Prospective assessment of trocar-specific morbidity in laparoscopy.

BACKGROUND: The purpose of the present study was to challenge the hypothetical advantage of single port laparoscopy (SPL) over conventional laparoscopy by measuring prospectively the morbidity specifically related to conventional trocar sites (TS). METHODS: From November 2010 to December 2011, 300 patients undergoing various laparoscopic procedures were enrolled. Patient, surgery, and trocar characteristics were recorded. We evaluated at three time points (in-hospital and at 1 and 6 months postoperatively) specifically for each TS, pain (Visual Analog Scale), morbidity (infection, hematoma, hernia), and cosmesis (Patient Scar Assessment Score; PSAS). Patients designated their "worst TS," and a composite endpoint "bad TS" was defined to include any adverse outcome at a TS. RESULTS: We analyzed 1,074 TS. Follow-up was >90 %. Pain scores of >3/10 at 1 and 6 months postoperatively, were reported by 3 and 1 % of patients at the 5 mm TS and by 9 and 1 % at the larger TS, respectively (5 mm TS vs larger TS; p = 0.001). Pain was significantly lower for TS located in the lower abdomen than for the upper abdomen or the umbilicus (p = 0.001). The overall complication rate was <1 % and significantly lower for the 5 mm TS (hematoma p = 0.046; infection p = 0.0001). No hernia was found. The overall PSAS score was low and significantly lower for the 5 mm TS (p = 0.0001). Significant predictors of "bad TS" were larger TS (p = 0.001), umbilical position (p = 0.0001), emergency surgery (p = 0.0001), accidental trocar exit (p = 0.022), fascia closure (p = 0.006), and specimen extraction site (p = 0.0001). CONCLUSIONS: Specific trocar morbidity is low and almost negligible for 5 mm trocars. The umbilicus appears to be an unfavorable TS.

Clinical and radiological findings in Pallister-Killian syndrome.

Pallister-Killian syndrome (PKS) is a potentially lethal disorder with facial dysmorphism, pigmentary skin anomalies, developmental delay and major visceral anomalies, such as diaphragmatic hernia, anorectal malformation, and congenital heart disease. PKS is causally associated with mosaic tetrasomy of chromosome 12p. A routine chromosome analysis in peripheral lymphocytes usually fails to detect the mosaic state. A prompt diagnosis rests on clinical awareness and a subsequent chromosome or molecular analysis in fibroblasts, buccal mucosal cells, or bone marrow cells. We report here on three infants with PKS. One infant had aortic dilatation, a previously unreported association in PKS. More importantly, all infants showed a recognizable, though mild, pattern of skeletal changes mainly affecting axial bones, including delayed ossification of the vertebral bodies and pubic bones, flared anterior ribs, and broad metaphyses of the long bones, particularly of the femora. These skeletal changes should be considered as a useful diagnostic sign in PKS. Awareness of the axial skeletal alterations can be helpful in prompting clinicians to search for mosaic tetrasomy 12p and perform chromosomal analysis in appropriate tissue types.

Gastrointestinal disease following heart transplantation.

With advances in heart transplantation, a growing number of recipients are at risk of developing gastrointestinal disease. We reviewed our experience with gastrointestinal disease in 92 patients undergoing 93 heart transplants. All had follow-up, with the median time 4.8 years (range 0.5-9.6 years). During the period of the study we progressively adopted a policy of low immunosuppression aiming toward monotherapy with cyclosporine. Nineteen patients (20.6%) developed 28 diseases related to the gastrointestinal tract. Thirteen patients required 18 surgical interventions, five as emergencies: closure of a duodenal ulcer, five cholecystectomies (one with biliary tract drainage), a sigmoid resection for a diverticulitis with a colovesical fistula, a colostomy followed by a colostomy takedown for an iatrogenic colon perforation, appendectomy, two anorectal procedures, and six abdominal wall herniorrhaphies. At the onset of gastrointestinal disease, 8 patients were on standard triple-drug immunosuppression, all of them within 6 months of transplantation; 13 were on double-drug immunosuppression; and 7 were on cyclosporine alone. All the patients with perforations/fistulas were on steroids. Among the 11 infectious or potentially infectious diseases, 10 were on triple- or double-drug immunosuppression. One death, a patient who was on triple-drug immunosuppression, had a postmortem diagnosis of necrotic and hemorrhagic pancreatitis. Except for an incisional hernia following a laparoscopic cholecystectomy, there was no morbidity and, importantly, no septic complications. We concluded that a low immunosuppression policy is likely to be responsible for the low morbidity and mortality of posttransplant gastrointestinal disease, with a lower incidence of viscous perforation/fistula and infectious gastrointestinal disease.

Measures to prevent surgical site infections: what surgeons (should) do.

BACKGROUND: The present study was designed to evaluate surgeons' strategies and adherence to preventive measures against surgical site infections (SSIs). MATERIALS AND METHODS: All surgeons participating in a prospective Swiss multicentric surveillance program for SSIs received a questionnaire developed from the 2008 National (United Kingdom) Institute for Health and Clinical Excellence (NICE) clinical guidelines on prevention and treatment of SSIs. We focused on perioperative management and surgical technique in hernia surgery, cholecystectomy, appendectomy, and colon surgery (COL). RESULTS: Forty-five of 50 surgeons contacted (90%) responded. Smoking cessation and nutritional screening are regularly propagated by 1/3 and 1/2 of surgeons, respectively. Thirty-eight percent practice bowel preparation before COL. Preoperative hair removal is routinely (90%) performed in the operating room with electric clippers. About 50% administer antibiotic prophylaxis within 30 min before incision. Intra-abdominal drains are common after COL (43%). Two thirds of respondents apply nonocclusive wound dressings that are manipulated after hand disinfection (87%). Dressings are usually changed on postoperative day (POD) 2 (75%), and wounds remain undressed on POD 2-3 or 4-5 (36% each). CONCLUSIONS: Surgeons' strategies to prevent SSIs still differ widely. The adherence to the current NICE guidelines is low for many procedures regardless of the available level of evidence. Further research should provide convincing data in order to justify standardization of perioperative management.

Hématome des muscles ilio-psoas: rappel des éléments diagnostiques

Introduction: La survenue d'une hémorragie dans les muscles iliopsoasconstitue une pathologie grave, dont le diagnostic est souventtardif et grevé d'une morbidité importante. Sa présentation cliniquedoit être reconnue précocement, en particulier par les médecins depremier recours.Cas clinique: Un patient de 65 ans est admis aux urgences en raisonde douleurs invalidantes de la jambe droite, prédominant sur la faceantérieure de la cuisse. Les douleurs irradient dans le pli inguinal, leflanc, la région lombaire, ainsi que la hanche droite. Elles sont associéesà une parésie du quadriceps droit. Le patient a bénéficié en2006 d'un remplacement de valve aortique, avec implantation d'unevalve mécanique motivant une anticoagulation par acenocoumarol.Il présente par ailleurs une parésie sur le territoire du nerf sciatiquedroit, après fracture du bassin en 1970. Le diagnostic est évoqué auvu d'une antioagulation supra-thérapeutique (INR 5).Un CT-scan de l'abdomen confirmera un important hématome(11 x 7 cm) du muscle iliaque droit (fig. 1) qui sera drainé chirurgicalement,après réversion partielle de la crase, permettant une évolutionfavorable.Discussion: Les hématomes des muscles ilio-psoas surviennentclassiquement de manière spontanée. Les symptômes sont peu spécifiques,à type de douleurs diffuses abdominales, lombaires ou crurales,de paresthésies, de limitation fonctionnelle ou de chute isoléede l'hémoglobine (Hb). Les patients sous anticoagulants (héparine,acenocoumarol) ou présentant des troubles de la coagulation (hémophilie,thrombopathie, maladie de von Willebrand) sont particulièrementà risque. Les complications sont fréquentes: compressions dunerf fémoral (avec hypoesthésie, parésie du quadriceps ou abolitiondu réflexe rotulien), anémie, état de choc. Le traitement implique lacorrection des troubles de la coagulation, ainsi qu'un suivi clinique,radiologique et biologique (Hb) régulier. Le traitement conservateurest proposé lors d'hématome de petite taille, si le patient est stable etpeu symptomatique. Dans les autres cas, un drainage chirurgical parvoie ouverte ou par voie percutanée est recommandé. L'embolisationartérielle s'affiche comme une future option thérapeutique.Conclusions: Ce cas illustre les différents éléments cliniques etbiologiques qui orientent précocement vers le diagnostic d'hématomedes muscles ilio-psoas. Il devrait favoriser l'évocation d'une pathologierare, permettant de garantir un diagnostic précoce.

Weaver syndrome and EZH2 mutations: Clarifying the clinical phenotype.

Weaver syndrome, first described in 1974, is characterized by tall stature, a typical facial appearance, and variable intellectual disability. In 2011, mutations in the histone methyltransferase, EZH2, were shown to cause Weaver syndrome. To date, we have identified 48 individuals with EZH2 mutations. The mutations were primarily missense mutations occurring throughout the gene, with some clustering in the SET domain (12/48). Truncating mutations were uncommon (4/48) and only identified in the final exon, after the SET domain. Through analyses of clinical data and facial photographs of EZH2 mutation-positive individuals, we have shown that the facial features can be subtle and the clinical diagnosis of Weaver syndrome is thus challenging, especially in older individuals. However, tall stature is very common, reported in >90% of affected individuals. Intellectual disability is also common, present in ~80%, but is highly variable and frequently mild. Additional clinical features which may help in stratifying individuals to EZH2 mutation testing include camptodactyly, soft, doughy skin, umbilical hernia, and a low, hoarse cry. Considerable phenotypic overlap between Sotos and Weaver syndromes is also evident. The identification of an EZH2 mutation can therefore provide an objective means of confirming a subtle presentation of Weaver syndrome and/or distinguishing Weaver and Sotos syndromes. As mutation testing becomes increasingly accessible and larger numbers of EZH2 mutation-positive individuals are identified, knowledge of the clinical spectrum and prognostic implications of EZH2 mutations should improve.

Helical tomotherapy for the treatment of anal canal cancer: a dosimetric comparison with 3D conformal radiotherapy.

AIMS AND BACKGROUND: The standard treatment of anal canal cancer (ACC) is combined chemotherapy and radiation therapy (RT), which is complex because of the shape of the target volumes and the need to minimize the irradiation of normal pelvic structures. In this study we compared the dosimetric results of helical tomotherapy (HT) plans with traditional 3D conformal RT (3DRT) plans for the treatment of ACC. METHODS AND STUDY DESIGN: Twelve patients (median age 57 years, range 38-83; F/M 8/4) treated with HT and concurrent chemotherapy for locally advanced ACC were selected. All had histologically confirmed squamous-cell carcinoma. A clinical target volume including the tumor and pelvic and inguinal lymph nodes was treated with HT to a total dose of 36 Gy in 1.8-Gy daily fractions. Then a sequential boost of 23.4 Gy in 1.8-Gy daily fractions (total dose 59.4 Gy) was delivered to the tumor and involved nodes. For all 12 patients, 3DRT plans were generated for comparison. Treatment plans were evaluated by means of standard dose-volume histograms. Dose coverage of the planning target volumes (PTVs), homogeneity index (HI), and mean doses to organs at risk (OARs) were compared. RESULTS: The coverage of PTV was comparable between the two treatment plans. HI was better in the HT vs. 3DRT plans (1.25 and 3.57, respectively; p<0.0001). HT plans resulted in better sparing of OARs (p<0.0001). CONCLUSIONS: HT showed superior target dose conformality and significant sparing of pelvic structures compared with 3DRT. Further investigation should determine if these dosimetric improvements will improve clinical outcomes regarding locoregional control, survival, and treatment-related acute and late morbidity.

Tumor de Wilms extra-renal: relato de caso

Um caso de tumor de Wilms extra-renal de localização retroperitoneal em uma paciente do sexo feminino de dois anos de idade é apresentado, associado a revisão de literatura. Foram realizados exames de radiografia simples do abdome, urografia excretora, ultra-sonografia e tomografia computadorizada sem e com contraste, que evidenciaram a presença de massa retroperitoneal adjacente ao rim direito. A paciente foi submetida a intervenção cirúrgica, com ressecção de toda a massa, sendo o diagnóstico de tumor de Wilms confirmado com exame anatomopatológico. O tumor de Wilms extra-renal é uma entidade extremamente rara e maligna, descrito na literatura principalmente sob a forma de relato de caso. Pode ocorrer no retroperitônio, útero e ovários, canal inguinal, testículos, pele, e até mesmo no tórax. O mecanismo exato que poderia explicar a ocorrência deste tumor em tecido extra-renal não foi bem estabelecido ainda. O diagnóstico é feito através do estudo anatomopatológico da lesão, geralmente após intervenção cirúrgica.

A Novel Approach to Major Surgery: Tracking Its Pathophysiologic Footprints.

BACKGROUND: To study the 'metabolic profile' of different surgical procedures and correlate it with pertinent surgical details and postoperative complications. METHODS: We conducted a prospective pilot study of 70 patients, ten for each of the seven following groups: (1) laparoscopic cholecystectomy, (2) incisional hernia repair, (3) laparoscopic and (4) open colon surgery, (5) upper gastrointestinal, (6) hepatic, and (7) pancreatic resections. Biochemical assessment included white blood cell count (WBC), C-reactive protein (CRP), glucose, triglycerides (TG), albumin (Alb), and pre-albumin (Pre-Alb), from the day before surgery until 5 days thereafter. Biological markers were compared for major versus minor surgery groups, which were defined on a clinical basis. Univariable analysis was used to identify risk factors for postoperative complications and p < 0.05 was the significance threshold. RESULTS: Common findings in all surgery groups were the acute inflammatory response (↑: WBC, CRP, ↓: TG, Alb, pre-Alb). Using cut-off values of 240 min operative (OR) time and 300 ml estimated blood loss (EBL), laparoscopic cholecystectomy, incisional hernia repair, and laparoscopic colectomy could be distinguished from open colectomy, upper gastrointestinal, liver, and pancreas resections. In a biochemical level, increased CRP and reduced postoperative Alb levels were highly discriminative of all types of 'major surgery.' Significant risk factors for postoperative complications were age, male gender, malignancy, longer OR time, higher blood loss, high CRP, and low Alb levels. CONCLUSIONS: Biochemically, CRP and Alb levels can help quantify the magnitude of the surgical trauma, which is correlated with adverse outcomes.

Imaging findings in fetal diaphragmatic abnormalities.

Imaging plays a key role in the detection of a diaphragmatic pathology in utero. US is the screening method, but MRI is increasingly performed. Congenital diaphragmatic hernia is by far the most often diagnosed diaphragmatic pathology, but unilateral or bilateral eventration or paralysis can also be identified. Extralobar pulmonary sequestration can be located in the diaphragm and, exceptionally, diaphragmatic tumors or secondary infiltration of the diaphragm from tumors originating from an adjacent organ have been observed in utero. Congenital abnormalities of the diaphragm impair normal lung development. Prenatal imaging provides a detailed anatomical evaluation of the fetus and allows volumetric lung measurements. The comparison of these data with those from normal fetuses at the same gestational age provides information about the severity of pulmonary hypoplasia and improves predictions about the fetus's outcome. This information can help doctors and families to make decisions about management during pregnancy and after birth. We describe a wide spectrum of congenital pathologies of the diaphragm and analyze their embryological basis. Moreover, we describe their prenatal imaging findings with emphasis on MR studies, discuss their differential diagnosis and evaluate the limits of imaging methods in predicting postnatal outcome.

Recién nacido con imagen torácica densa

Presentamos un recien nacido varón de 48 horas de vida que ingresa por cianosis, bradicardia e hipotonia. Es fruto de la séptima gestación de una madre añosa de 41 años de edad entre cuyos antecedentes sólo resaltan tres abortos previos al embarazo actual, dos de ellos provocados.Este embarazo fue bien controlado..