Vascular injury is associated with repetitive head impacts and tau pathology in chronic traumatic encephalopathy

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease linked to repetitive head impacts (RHI) and characterized by perivascular hyperphosphorylated tau (p-tau) deposits. The role of vascular injury, blood-brain barrier leakage, and neuroinflammation in CTE pathogenesis is not well understood. We performed quantitative immunoassays for intercellular adhesion molecule 1 (ICAM1), vascular cellular adhesion molecule 1 (VCAM1), and C-reactive protein (CRP) within the postmortem dorsolateral frontal cortex of participants with and without a history of RHI and CTE (n = 156), and tested for associations with RHI, microgliosis, and tau pathology measures. Levels of vascular injury-associated markers ICAM1, VCAM1, and CRP were increased in CTE compared to RHI-exposed and -naïve controls. ICAM1 and CRP increased with RHI exposure duration (p < 0.01) and were associated with increased microglial density (p < 0.001) and tau pathology (AT8, p-tau396, p-tau202; p < 0.05). Histologically, there was significantly increased ICAM1 staining of the microvasculature, extracellular space, and astrocytes at the sulcal depths in high stage CTE compared to both low stage CTE and controls. Multifocal perivascular immunoreactivity for serum albumin was present in all RHI-exposed individuals. These findings demonstrate that vascular injury markers are associated with RHI exposure, duration, and microgliosis, are elevated in CTE, and increase with disease severity.

Tau Pathology in Chronic Traumatic Encephalopathy is Primarily Neuronal

Millions of individuals are exposed to repetitive head impacts (RHI) each year through contact sports, military blast, and interpersonal violence. RHI is the major risk factor for developing chronic traumatic encephalopathy (CTE), a neurodegenerative tauopathy. Recent consensus criteria defined the pathognomonic lesion in CTE as perivascular, hyperphosphorylated tau (p-tau) in neuronal aggregates. Astroglial p-tau is an inconsistent supporting feature and not in itself diagnostic of CTE. This study quantitated the spatial and cellular distribution of p-tau pathology in postmortem dorsolateral frontal cortex of 150 individuals with CTE, from ages 21 to 80 years old, without comorbid pathology. p-Tau-immunoreactive cells were quantitated in the gray matter sulcus, crest, subpial region, and within pathognomonic CTE lesions. Significantly more neuronal p-tau than astrocytic p-tau was found across all cortical regions (p &lt; 0.0001). Sulcal astrocytic p-tau was primarily (75%, p &lt; 0.0001) localized to subpial regions as thorn-shaped astrocytes, a form of age-related tau astrogliopathy. Neuronal p-tau was significantly associated with age, years of RHI exposure, and CTE severity; astrocytic p-tau pathology was only significantly associated with age. These findings strongly support neuronal degeneration as a driving feature of CTE and will help inform future research and the development of fluid biomarkers for the detection of neuronal degeneration in CTE.

Tau phosphorylation sites serine202 and serine396 are differently altered in chronic traumatic encephalopathy and Alzheimer's disease

INTRODUCTION

Chronic traumatic encephalopathy (CTE) is a neurodegenerative tauopathy associated with repetitive head impacts (RHI) typically sustained by contact sport athletes. Post-translation modifications to tau in CTE have not been well delineated or compared to Alzheimer's disease (AD).

METHODS

We measured phosphorylated tau epitopes within dorsolateral frontal cortex from post mortem brains with neither CTE nor AD (n = 108), CTE (n = 109), AD (n = 223), and both CTE and AD (n = 33).

RESULTS

Levels of hyperphosphorylated tau (p-tau)202 , p-tau231 , and p-tau396 were significantly increased in CTE. Total years of RHI exposure was significantly associated with increased p-tau202 levels (P = .001), but not p-tau396 . Instead, p-tau396 was most closely related to amyloid beta (Aβ)1-42 levels (P < .001). The p-tau202 :p-tau396 ratio was significantly increased in early and late CTE compared to AD.

DISCUSSION

In frontal cortex, p-tau202 is the most upregulated p-tau species in CTE, while p-tau396 is most increased in AD. p-tau202 and p-tau396 measurements may aid in developing biomarkers for disease.

Differential gene expression in the cortical sulcus compared to the gyral crest within the early stages of chronic traumatic encephalopathy

Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative tauopathy found in individuals with a history of repetitive head impacts (RHI). Previous work has demonstrated that neuroinflammation is involved in CTE pathogenesis, however, the specific inflammatory mechanisms are still unclear. Here, using RNA-sequencing and gene set enrichment analysis (GSEA), we investigated the genetic changes found in tissue taken from the region CTE pathology is first found, the cortical sulcus, and compared it to neighboring gryal crest tissue to identify what pathways were directly related to initial hyperphosphorylated tau (p-tau) deposition. 21 cases were chosen for analysis: 6 cases had no exposure to RHI or presence of neurodegenerative disease (Control), 5 cases had exposure to RHI but no presence of neurodegenerative disease (RHI), and 10 cases had exposure to RHI and low stage CTE (CTE). Two sets of genes were identified: genes that changed in both the sulcus and crest and genes that changed specifically in the sulcus relative to the crest. When examining genes that changed in both the sulcus and crest, GSEA demonstrated an increase in immune related processes and a decrease in neuronal processes in RHI and CTE groups. Sulcal specific alterations were observed to be driven by three mechanisms: anatomy, RHI, or p-tau. First, we observed consistent sulcal specific alterations in immune, extracellular matrix, vascular, neuronal, and endocytosis/exocytosis categories across all groups, suggesting the sulcus has a unique molecular signature compared to the neighboring crest independent of pathology. Second, individuals with a history of RHI demonstrated impairment in metabolic and mitochondrial related processes. Finally, in individuals with CTE, we observed impairment of immune and phagocytic related processes. Overall, this work provides the first observation of biological processes specifically altered in the sulcus that could be directly implicated in CTE pathogenesis and provide novel targets for biomarkers and therapies.

Diabetes management during cardiac surgery in the UK: A survey

AIM

To determine current practice regarding the diabetes management of people undergoing cardiac surgery in the UK.

METHODS

We conducted an online survey of UK cardiothoracic surgeons. All cardiothoracic surgeons listed in the Society of Cardiothoracic Surgery membership directory were invited to participate. The survey, compiled using SurveyMonkey software, comprised 15 closed and open-ended questions about the management of people with diabetes pre- and peri-operatively.

RESULTS

Sixty-two cardiothoracic surgeons from all 33 UK cardiac centres completed the survey. Of these, 44% responded that they routinely measure HbA_1c preoperatively for all patients, 19% had an HbA_1c threshold above which they would not operate and 21% currently undertake a point-of-care HbA_1c measurement during the cardiothoracic outpatient visit. A total of 74% of respondents reported that it was 'easy' or 'very easy' to obtain a diabetes team review; diabetes nurse specialists were the members of the diabetes team working most closely with cardiac surgeons. Up to a third of the surgeons did not provide physical activity recommendations prior to admission and over 80% did not have a different preoperative or surgical diabetes protocol. Inconsistency in the responses within centres suggests that differences in practice may depend on individual surgeons rather than local policy.

CONCLUSIONS

The study demonstrates there is only limited peri-operative management of diabetes in people undergoing cardiac surgery in the UK. There is an opportunity for greater involvement of the diabetes specialist team both before and during admission for surgery to improve outcomes. (Trial registration: ISRCTN10170306).

Three-point transfusion risk score in hepatectomy

BACKGROUND

Perioperative red blood cell transfusions are required in up to 23 per cent of patients undergoing hepatectomy. Previous research has developed three transfusion risk scores to assess risk of perioperative red blood cell transfusion. Here, the performance of these transfusion risk scores was evaluated in a multicentre cohort of patients who underwent hepatectomy and compared with that of a simplified transfusion risk score.

METHODS

A database of patients undergoing hepatectomy at four specialized centres between 2008 and 2012 was developed. External validity was assessed by discrimination and calibration. Discrimination was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration was evaluated by the degree of agreement between predicted and actual red blood cell transfusion probabilities. A simplified transfusion risk score using variables common to the three models was created, and discrimination and calibration were evaluated.

RESULTS

There were 1287 patients included in this study, with 341 (26·5 per cent) receiving a red blood cell transfusion. Discriminative ability was similar between the three transfusion risk scores, with AUCs of 0·66-0·68 and good calibration. A new three-point risk score was developed based on factors present in all models: haemoglobin 12·5 g/dl or less, primary liver malignancy and major resection (at least 4 segments). Discriminative ability and calibration of the three-point model were similar to those of the three existing models, with an AUC of 0·66.

CONCLUSION

The three-point transfusion risk score simplifies assessment of perioperative transfusion risk in hepatectomy without sacrificing predictive ability.

Characterization of Colletotrichum Species Causing Bitter Rot of Apple in Kentucky Orchards

Multiple species of Colletotrichum can cause bitter rot disease of apple, but the identities and relative representation of the species causing the disease in Kentucky are unknown. In total, 475 Colletotrichum isolates were collected from diseased apple fruit in 25 counties and characterized both morphologically and by using various molecular approaches. Multigene sequence analyses revealed that sample isolates belonged to several newly erected species within the Colletotrichum acutatum and C. gloeosporioides species complexes. The isolates were identified as C. fioriniae and C. nymphaeae, which reside within the C. acutatum species complex, and C. siamense, C. theobromicola, and C. fructicola, which are placed within the C. gloeosporioides species complex. C. fioriniae was the most common species causing bitter rot in Kentucky, comprising more than 70% of the isolates. Infectivity tests on detached fruit showed that C. gloeosporioides species-complex isolates were more aggressive than isolates in the C. acutatum species complex. However, isolates within the C. acutatum species complex produced more spores on lesions compared with isolates within the C. gloeosporioides species complex. Aggressiveness varied among individual species within a species complex. C. siamense was the most aggressive species identified in this study. Within the C. acutatum species complex, C. fioriniae was more aggressive than C. nymphaeae, causing larger, deeper lesions. Apple cultivar did not have a significant effect on lesion development. However, Colletotrichum spp. produced more spores on 'Red Stayman Winesap' than on 'Golden Delicious'. Fungicide sensitivity tests revealed that the C. acutatum species complex was more tolerant to thiophanate-methyl, myclobutanil, trifloxystrobin, and captan compared with the C. gloeosporioides species complex. The study also revealed that mycelial growth of C. siamense was more sensitive to tested fungicides compared with C. fructicola and C. theobromicola. These research findings emphasize the importance of accurate identification of Colletotrichum spp. within each species complex, because they exhibit differences in pathogenicity and fungicide sensitivity.

Expert opinion on advanced techniques for hemostasis in liver surgery

BACKGROUND

Reduction of perioperative blood loss and intraoperative transfusion are two major factors associated with improving outcomes in liver surgery. There is currently no consensus as to the best technique to achieve this.

METHODS

An international Panel of Experts (EP), made up of hepatobiliary surgeons from well-known high-volume centres was assembled to share their experience with regard to the management of blood loss during liver resection surgery. The process included: a review of the current literature by the panel, a face-to-face meeting and an on-line survey completed by the EP prior to and following the face-to-face meeting, based on predetermined case scenarios. During the meeting the most frequently researched surgical techniques were appraised by the EP in terms of intraoperative blood loss.

RESULTS

All EP members agreed that high quality research on the subject was lacking. Following an agreed risk stratification algorithm, the EP concurred with the existing research that a haemostatic device should always be used along with any user preferred surgical instrumentation in both open and laparoscopic liver resection procedures, independently from stratification of bleeding risk. The combined use of Ultrasonic Dissector (UD) and saline-coupled bipolar sealing device (Aquamantys(®)) was the EP preferred technique for both open and laparoscopic surgery.

CONCLUSIONS

This EP propose the use of a bipolar sealer and UD for the best resection technique and essential equipment to minimise blood loss during liver surgery, stratified according to transfusion risk, in both open and laparoscopic liver resection.

Hepatic arterial infusion pump chemotherapy in the management of colorectal liver metastases: expert consensus statement

Despite significant improvements in systemic therapy for patients with colorectal liver metastases (crlms), response rates in the first-line setting are not optimal, and response rates in the second-line setting remain disappointing. Hepatic arterial infusion pump (haip) chemotherapy has been extensively studied in patients with crlms, but it remains infrequently used. We convened an expert panel to discuss the role of haip in the contemporary management of patients with crlm. Using a consensus process, we developed these statements: haip chemotherapy should be given in combination with systemic chemotherapy.haip chemotherapy should be offered in the context of a multidisciplinary program that includes expertise in hepatobiliary surgery, medical oncology, interventional radiology, nursing, and nuclear medicine.haip chemotherapy in combination with systemic therapy should be considered in patients with unresectable crlms who have progressed on first-line systemic treatment. In addition, haip chemotherapy is acceptable as first-line treatment in patients with unresectable colorectal liver metastases.haip chemotherapy is not recommended in the setting of extrahepatic disease outside the context of a clinical trial.haip chemotherapy in combination with systemic therapy is an option for select patients with resected colorectal liver metastases. These consensus statements provide a framework that clinicians who treat patients with crlm can use when considering treatment with haip.

First Report of Impatiens Downy Mildew Caused by Plasmopara obducens in Kentucky

Impatiens downy mildew (Plasmopara obducens (J. Schröt.) J. Schröt. (syn Peronospora obducens) was first reported in the United States in 2004, but widespread outbreaks were observed throughout North America in 2011 (5). In June 2012, symptoms, including severe defoliation while plants retained upright stems, were observed on approximately 100 landscape impatiens (Impatiens walleriana Hook.f.) in Franklin County in central Kentucky. All plants in the landscape were affected. Plants were primarily defoliated and remaining leaves were stunted, mottled, and chlorotic with edges curled downward; no flowers were present. Under examination with a dissecting microscope, white downy fungal growth was observed. Closer examination confirmed that the growth consisted of colorless sporangiophores that were mainly unbranched, straight, and rigid (1,3). Sporangiophores consisted of apical branches attached at right angles to main axes, ranging from 67.2 to 89.9 μm long (1). Sporangia were ovoid and hyaline, measuring 11.2 to 13.3 μm × 8.2 to 10.7 μm (3). No oospores were observed. Pathogenicity tests were performed by inoculating 20 to 40 leaves on three plants each of the cvs. Dazzler and Super Elfin with suspensions of 1 × 10⁵ sporangiophores per ml in sterile distilled water. Sporangia were obtained by washing infected leaves with sterile distilled water, and inoculations were completed by spraying leaves until runoff. Plants sprayed with sterile water served as controls. Plants were covered with black plastic bags for 48 h and then maintained under fluorescent lights for 10 days at room temperature (22 to 25°C). Sporangiophores were recovered from inoculated plants after 10 days, and morphology matched original inoculum; symptoms included chlorotic, downward curling leaves with sporulation on the undersides. Non-inoculated plants did not develop symptoms after 21 days. Molecular identification of the pathogen was conducted using three leaves from one plant from each cultivar. PCR was conducted by amplifying the large ribosomal subunit DNA using primers NL-1 and NL-4 (2). Amplicons of 762 to 691 bp were produced from diseased plant tissue that contained visible sporangiophores, and the bands were extracted from the gel and purified. Sequence results confirmed 100% similarity to accessions from Florida (GenBank Accession No. JX217746.1) and Ohio (JX142134.1) and 99% similarity to amplicons reported from Serbia (HQ246451.1) and UK (AY587558.1). This is believed to be the first report of downy mildew infecting impatiens in Kentucky. References: (1) O. Constantinescu. Mycologia 83:473, 1991. (2) W. Maier et al. Can. J. Bot 81:12, 2003. (3) P. A. Saccardo. Syllogue Fungorum 7:242, 1888. (4) S. N. Wegulo et al. Plant Dis. 88:909, 2004.

Report from the 13th annual Western canadian gastrointestinal cancer consensus conference; calgary, alberta; september 8-10, 2011

The 13th annual Western Canadian Gastrointestinal Cancer Consensus Conference was held in Calgary, Alberta, September 8-10, 2011. Health care professionals involved in the care of patients with gastrointestinal cancers participated in presentation and discussion sessions for the purposes of developing the recommendations presented here. This consensus statement addresses current issues in the management neuroendocrine tumours and locally advanced pancreatic cancer.

Bio-monitoring for uranium using stream-side terrestrial plants and macrophytes

This study evaluated the abilities of various plant species to act as bio-monitors for environmental uranium (U) contamination. Vegetation and soil samples were collected from a U processing facility. The water-way fed from facility storm and processing effluents was the focal sample site as it represented a primary U transport mechanism. Soils and sediments from areas exposed to contamination possessed U concentrations that averaged 630 mg U kg(-1). Aquatic mosses proved to be exceptional accumulators of U with dry weight (dw) concentrations measuring as high as 12,500 mg U kg(-1) (approximately 1% of the dw mass was attributable to U). The macrophytes (Phragmites communis, Scripus fontinalis and Sagittaria latifolia) were also effective accumulators of U. In general, plant roots possessed higher concentrations of U than associated upper portions of plants. For terrestrial plants, the roots of Impatiens capensis had the highest observed levels of U accumulation (1030 mg kg(-1)), followed by the roots of Cyperus esculentus and Solidago speciosa. The concentration ratio (CR) characterized dry weight (dw) vegetative U levels relative to that in associated dw soil. The plant species that accumulated U at levels in excess of that found in the soil were: P. communis root (CR, 17.4), I. capensis root (CR, 3.1) and S. fontinalis whole plant (CR, 1.4). Seven of the highest ten CR values were found in the roots. Correlations with concentrations of other metals with U were performed, which revealed that U concentrations in the plant were strongly correlated with nickel (Ni) concentrations (correlation: 0.992; r-squared: 0.984). Uranium in plant tissue was also strongly correlated with strontium (Sr) (correlation: 0.948; r-squared: 0.899). Strontium is chemically and physically similar to calcium (Ca) and magnesium (Mg), which were also positively-correlated with U. The correlation with U and these plant nutrient minerals, including iron (Fe), suggests that active uptake mechanisms may influence plant U accumulation.

Effects of the dopaminergic agent and NMDA receptor antagonist amantadine on cognitive function, cerebral glucose metabolism and D2 receptor availability in chronic traumatic brain injury: A study using positron emission tomography (PET)

PRIMARY OBJECTIVE

This study was performed to assess effects of amantadine (AMH), a dopaminergic agent and NMDA antagonist, on chronic traumatic brain injury (TBI). The primary hypotheses were that amantadine treatment would result in executive function improvement and increased activity in pre-frontal cortex.

RESEARCH DESIGN

An open-label design was used.

METHODS

Twenty-two subjects underwent neuropsychological testing pre- and post-12 week treatment. Six subjects also underwent PET scanning.

INTERVENTION

Amantadine 400 mg was administered per day.

RESULTS

Significant improvements on tests of executive function were observed with treatment. Analysis of PET data demonstrated a significant increase in left pre-frontal cortex glucose metabolism. There was a significant positive correlation between executive domain scores and left pre-frontal glucose metabolism.

CONCLUSIONS

This is the first known study to assess amantadine in chronic TBI using PET and the data are consistent with the hypotheses. The conduction of further studies is warranted.

Transarterial chemoembolisation for advanced hepatocellular carcinoma: results from a North American cancer centre

AIMS

In Asian countries, transarterial chemoembolisation (TACE) has long been used for palliation of unresectable hepatocellular carcinoma (HCC) without strong evidence of improved survival or quality of life. In 2002, a survival benefi of TACE was shown in two randomised controlled trials in Europe and Hong Kong. The effectiveness of interventions fo HCC is influenced by geographical factors related to diverse patient characteristics and protocols. Therefore, the validation of TACE as palliative modality for unresectable HCC requires confirmation in diverse patient populations. The aim of the present study was to assess the effectiveness of TACE for HCC in a North American population.

MATERIALS AND METHODS

This was a single centre prospective cohort study. Child-Pugh A cirrhosis or better patients wit unresectable HCC and without radiological evidence of metastatic disease or segmental portal vein thrombosis wer assessed between November 2001 and May 2004. Of 54 patients who satisfied the inclusion criteria, 47 underwent 80 TACE sessions. Chemoembolisation was carried out using selective hepatic artery injection of 75 mg/m(2) doxorubicin and lipiodol followed by an injection of embolic particles when necessary. Repeat treatments were carried out at 2-3 month intervals for recurrent disease. The primary outcome was overall survival; secondary outcomes were morbidity and tumour response.

RESULTS

The survival probabilities at 1, 2 and 3 years were 76.6, 55.5 and 50%, respectively. At 6 months after the first intervention, 31% of patients had a partial response and 60% had stable disease by RECIST criteria. Minor adverse events occurred after 39% of TACEs and major adverse events after 20% of sessions, including two treatment-related deaths (4% of patients). One patient had complete cancer remission after undergoing three TACE treatments. Further progression of tumour growth was prevented in 91% of tumours at the 6 month point after the first TACE. At 3 months, serum levels of the tumour marker alpha-feto protein were significantly reduced in patients with elevated levels before TACE.

CONCLUSIONS

The survival probabilities at 1 and 2 years after TACE were comparable with results in randomised studies from Europe and Asia. Most patients tolerated TACE well, but clinicians need to be aware that moderately severe sideeffects require close monitoring and prompt intervention.

Odourous algal-derived alkenes: differences in stability and treatment responses in drinking water

Drinking water supplies are often impacted by taste and odour (T/O) episodes caused by algal volatile organic compounds (AVOCs) from algal blooms. Treatment and control of these events is important to utility operators, as customer confidence in the safety of public drinking water supplies is based primarily on their palatability and odour. To manage T/O outbreaks successfully, knowledge about treatment responses of AVOCs and anticipation of their outbreaks are thus of major importance to the water industry. The Glenmore Reservoir and water treatment plant (GWTP) supplies drinking water to over 50% of the ca. 1 million consumers in Calgary (Alberta). Despite low nutrients and high raw water quality, the reservoir experiences periodic outbreaks of fishy/floral T/O, caused by chrysophytes and diatoms (Uroglena americana, Dinobryon spp., Synura petersenii, Asterionella formosa). These odours are produced by the unsaturated C7-C10 alkenes 2,4-heptadienal, 2,4,7-octatriene, 2,4-decadienal and 2,4,7-decatrienal, generated during from the enzymatic breakdown of algal polyunsaturated fatty acids (PUFAs). The formation, persistence and stability of these compounds in both the raw water and treatment plant is not well understood.

Current role of radiofrequency ablation for the treatment of colorectal liver metastases

BACKGROUND AND METHOD

This paper reviews the current status of radiofrequency ablation in the treatment of colorectal liver metastases. Relevant studies with at least ten patients that reported rates of complete tumour ablation, local recurrence, or survival from 1 to 5 years after treatment were included in the review.

RESULTS AND CONCLUSION

Only six studies that reported at least 3-year survival were identified, with results ranging from 37 to 58 per cent. Some of these figures are promising, given that the patients were considered to have unresectable disease. However, available evidence is limited and hepatic resection remains the standard of care when feasible; radiofrequency ablation cannot be considered an equivalent. Radiofrequency ablation does, however, appear to have a role in treating unresectable disease, and may also be used in conjunction with resection to extend its limits.

Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy is the primary treatment for periampullary cancer. Associated morbidity is high and often related to pancreatic anastomotic failure. This paper compares rates of pancreatic fistula, morbidity and mortality after pancreaticoduodenectomy in patients having reconstruction by pancreaticogastrostomy with those in patients having reconstruction by pancreaticojejunostomy.

METHODS

A meta-analysis was performed of all large cohort and randomized controlled trials carried out since 1990.

RESULTS

Eleven articles were identified for inclusion: one prospective randomized trial, two non-randomized prospective trials and eight observational cohort studies. The meta-analysis revealed a higher rate of pancreatic fistula associated with pancreaticojejunostomy reconstruction (relative risk (RR) 2.62 (95 per cent confidence interval (c.i.) 1.91 to 3.60)). A higher overall morbidity rate was also demonstrated in this group (RR 1.43 (95 per cent c.i. 1.26 to 1.61)), as was a higher mortality rate (RR 2.51 (95 per cent c.i. 1.61 to 3.91)).

CONCLUSION

Current literature suggests that the safer means of pancreatic reconstruction after pancreaticoduodenectomy is pancreaticogastrostomy, but much of the evidence comes from observational cohort study data.

Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy

Background

Pancreaticoduodenectomy is the primary treatment for periampullary cancer. Associated morbidity is high and often related to pancreatic anastomotic failure. This paper compares rates of pancreatic fistula, morbidity and mortality after pancreaticoduodenectomy in patients having reconstruction by pancreaticogastrostomy with those in patients having reconstruction by pancreaticojejunostomy.

Methods

A meta-analysis was performed of all large cohort and randomized controlled trials carried out since 1990.

Results

Eleven articles were identified for inclusion: one prospective randomized trial, two non-randomized prospective trials and eight observational cohort studies. The meta-analysis revealed a higher rate of pancreatic fistula associated with pancreaticojejunostomy reconstruction (relative risk (RR) 2·62 (95 per cent confidence interval (c.i.) 1·91 to 3·60)). A higher overall morbidity rate was also demonstrated in this group (RR 1·43 (95 per cent c.i. 1·26 to 1·61)), as was a higher mortality rate (RR 2·51 (95 per cent c.i. 1·61 to 3·91)).

Conclusion

Current literature suggests that the safer means of pancreatic reconstruction after pancreaticoduodenectomy is pancreaticogastrostomy, but much of the evidence comes from observational cohort study data.

Laparoscopic incisional hernia repair: a review of the literature

Incisional hernia is a common long-term complication of abdominal surgery. Historically the open repair with or without mesh was the mainstay of treatment. However, many recently published laparoscopic repair studies have challenged surgeons to re-evaluate which technique provides the best short and long-term outcomes. A Medline search of all English-language literature was performed using the keywords 'incisional', 'ventral', 'hernia', 'laparoscopic', and 'open'. Further references were obtained by cross-referencing the bibliography in each paper. Current evidence suggests that the laparoscopic incisional hernia repair is the optimal surgical treatment. A laparoscopic repair appears to shorten hospital stay, decrease perioperative complication rates, and decrease recurrence rates. However, there is no randomized trial utilizing a standardized complication grading system making it difficult to draw a definitive conclusion as to which repair is best.

Management of a solid pseudopapillary tumor of the pancreas with liver metastases

BACKGROUND

Solid pseudopapillary tumor, otherwise known as solid and cystic tumor or Frantz tumor, is an unusual form of pancreatic carcinoma. Its natural history differs from the more common pancreatic adenocarcinoma in that it has a female predilection, is more indolent, and carries a better prognosis. Metastatic disease can occur, usually involving the liver, and its management is not well defined.

CASE OUTLINE

A young woman was found to have a tumor situated in the pancreatic tail with seven synchronous hepatic metastases. Segments II and III were free of metastatic disease. A needle biopsy of the pancreatic lesion was non-diagnostic but suggested that the lesion was unlikely to be a typical adenocarcinoma. Initial treatment consisted of a distal pancreatectomy, which confirmed the diagnosis of a solid pseudopapillary tumor. Given the indolent nature of this pathologic entity as well as the patient's youth, an aggressive approach to treatment of the hepatic metastases was recommended. Because the liver was fatty, the right portal vein was embolized to produce hypertrophy of the left hemiliver. Six weeks later an extended right hepatectomy cleared the hepatic disease. The patient had an uncomplicated recovery, and she remains disease-free at 22 months.

DISCUSSION

Solid pseudopapillary tumor of the pancreas is a rare malignancy. Survival following primary resection approaches 95% at 5 years. Metastatic disease, although rare, usually involves the liver and/or peritoneum. Given the paucity of reported cases, the management of metastatic disease is, to date, poorly defined. This case demonstrates a favorable short-term outcome with aggressive surgical treatment of both the primary and metastatic tumor.

Resistance to QoI (Strobilurin-like) Fungicides in Isolates of Pyricularia grisea from Perennial Ryegrass

In August 2000, azoxystrobin was ineffective in controlling gray leaf spot of perennial ryegrass at a golf course in Lexington, KY and at two golf courses in Illinois. Isolates suspected of being fungicide-resistant ("suspect isolates") were compared to "baseline" isolates obtained from sites with no known use of quinol-oxidizing inhibitor (Q_oI) fungicides. Conidial germination of Pyricularia grisea was tested in vitro with 100 μg of salicylhydroxamic acid per ml. For baseline isolates, 50% effective concentration (EC₅₀) values for azoxystrobin and trifloxystrobin were 0.015 to 0.064 and 0.013 to 0.078 μg/ml, respectively; EC₅₀ values for suspect isolates were 2.39 to 44.8 and 0.31 to 111, respectively. All suspect isolates exhibited significantly (P = 0.05) lower sensitivity to Q_oI fungicides than all baseline isolates. The mean EC₅₀ values for suspect isolates for azoxystrobin and trifloxystrobin were 690 and 827 times higher, respectively, than the means for baseline isolates. In the laboratory, azoxystrobin and trifloxystrobin provided essentially complete control of disease induced by nine baseline isolates in vivo. Azoxystrobin and trifloxystrobin provided poor to no control of disease induced by six of eight suspect isolates; control of disease induced by the remaining two isolates was partial for azoxystrobin and complete for trifloxystrobin. We conclude that one or more biotypes of perennial ryegrass-infecting strains of P. grisea with resistance to Q_oI fungicides have emerged. This is the first report of resistance to Q_oI fungicides in P. grisea. Furthermore, this is one of two Q_oIresistant fungal pathogens collected in the United States during the 2000 growing season, the first instances reported for North America.

Cystadenoma of the liver without mesenchymal stroma in a female following hormonal therapy for acne

BACKGROUND

Liver cystadenomas are relatively rare tumours that can be difficult to diagnose; treatment entails complete surgical extirpation either by either anatomical resection or enucleation.

CASE OUTLINE

A 19-year-old woman presented with acute onset of abdominal pain and was found to have a multilocular giant liver cyst.The cyst was percutaneously drained; CEA and CA 19-9 tumour markers were elevated in this cyst fluid: CEA 96 microg/L, CAI9-9 37 550 kU/L. The cyst was completely enucleated and has not recurred. Pathological examination confirmed a cystadenoma without mesenchymal stroma, and tumour oestrogen and progesterone receptors were negative.

DISCUSSION

This is the fourth report of a liver cystadenoma without mesenchymal stroma in a female and the first to document elevated cyst fluid tumour markers. This case also illustrates the possible relationship between hormonal therapy and tumour growth.

Feasibility of sentinel lymph node biopsy and lymphatic mapping in nodular thyroid neoplasms

Although the prognostic significance of occult lymph node metastases in thyroid cancer remains controversial, identifying these patients may help direct therapy. The purpose of this study was to determine the feasibility and safety of sentinel lymph node biopsy (SLNBx) in thyroid nodular disease. Patients undergoing thyroid resection, with no evidence of clinical lymphadenopathy, were enrolled. The nodule was injected with isosulfan blue vital dye. Blue-stained lymphatic channels were traced within the central compartment to the SLN, which was excised. A total of 40 patients underwent SLNBx; lymphatics were seen in 31 patients, and SLNs were found in 26. In 11 patients the lymphatic vessels were traced through the central compartment into the lateral or mediastinal compartments, although a central SLN was retrieved in only 6. Of the 18 patients with benign neoplasms, 14 had benign SLNs, and no SLN was found in 4. A thyroid lymphoma patient had a true positive SLN. In the 12 patients with papillary thyroid cancer (PTC), 6 had true positive SLNs, and 2 had a true negative SLN. In one patient with metastatic PTC, the parathyroid stained blue. Another patient with PTC had lateral lymphatic channels, but no SLN was found. There were two false negatives, proven by a node dissection in one and lateral uptake on (131)I scanning in the other. There were no postoperative complications. SLNBx for thyroid disease is feasible and safe. Potential staining of the parathyroids makes their identification before injection mandatory. The variable lymphatic drainage patterns and the two false-negative nodes indicate that further investigation is required before the procedure can be recommended for patients with thyroid disease.