Surgical management of perianal fistula using an ovine forestomach matrix implant

PURPOSE

Invasive surgical management of cryptoglandular perianal fistulas (PF) is challenging because of high recurrence rates and the potential for injury to the sphincter complex. In the present technical note, we introduce a minimally invasive treatment for PF using a perianal fistula implant (PAFI) comprising ovine forestomach matrix (OFM).

METHODS

This retrospective observational case series highlights 14 patients who had undergone a PAFI procedure at a single center between 2020 and 2023. During the procedure, previously deployed setons were removed and tracts were de-epithelialized with curettage. OFM was rehydrated, rolled, passed through the debrided tract, and secured in place at both openings with absorbable suture. Primary outcome was fistula healing at 8 weeks, and secondary outcomes included recurrence or postoperative adverse events.

RESULTS

Fourteen patients underwent PAFI using OFM with a mean follow-up period of 37.6 ± 20.1 weeks. In follow-up, 64% (n = 9/14) had complete healing at 8 weeks and all remained healed, except one at last follow-up visit. Two patients underwent a second PAFI procedure and were healed with no recurrence at the last follow-up visit. Of all patients that healed during the study period (n = 11), the median time to healing was 3.6 (IQR 2.9-6.0) weeks. No postprocedural infections nor adverse events were noted.

CONCLUSIONS

The minimally invasive OFM-based PAFI technique for PF treatment was demonstrated to be a safe and feasible option for patients with trans-sphincteric PF of cryptoglandular origin.

Serum lipid expression correlates with function and regeneration following living donor liver transplantation

Following living donor liver transplantation (LDLT; and unlike deceased donor liver transplantation [DDLT]), the liver must rapidly regenerate, and sometimes segmental graft dysfunction (SGD) is observed. Hepatic regeneration requires substantial de novo lipid synthesis, and we previously reported that expression of lipid-related genes is dysregulated in LDLT. Here, we compare serum lipid measurements in 41 LDLT recipients and 43 DDLT recipients at baseline and at serial posttransplant time points. In addition, we examined whether serum lipid/apolipoprotein (apo) levels correlate with the degree of liver regeneration (measured using percent volume increase [%VI] at 3 months) or SGD in LDLT recipients. In contrast to DDLT, lipid levels declined early after LDLT but returned to baseline by 30 days. The odds ratio (OR) for achieving robust regeneration (>90 %VI) was 2.53 (95% confidence interval [CI], 1.15-5.52) for every 1 mg/dL increase in serum apoE at 30 days. The OR of SGD for every year increase in donor age was 1.19 (95% CI, 1.02-1.39), and 0.61 for every 1 mg/dL increase in serum high-density lipoprotein cholesterol at 7 days (95% CI, 0.34-1.11). No associations were detected between preoperative serum lipids/apos in LDLT donors and SGD or %VI in recipients. In conclusion, we suggest that initiation of regeneration prevents the liver from participating fully in lipid transport and metabolism. Inability to meet systemic metabolic needs may result in compromised liver function and SGD. Certain serum lipid concentrations correlate with extent of liver regeneration and function.

Robotic trans-abdominal transplant nephrectomy for a failed renal allograft

Minimally invasive surgery for removal of a failed renal allograft has not previously been reported. Herein, we report the first robotic trans-abdominal transplant nephrectomy (TN). A 34-year-old male with Alport's syndrome lost function of his deceased donor allograft after 12 years and presented with fever, pain over his allograft and hematuria. The operation was performed intra-abdominally using the Da Vinci Robotic Surgical System with four trocars. The total operative time was 235 min and the estimated blood loss was less than 25 cm(3). There were no peri-operative complications observed and the patient was discharged to home less than 24 h postoperatively. The utilization of robotic technology facilitated the successful performance of a minimally invasive, trans-abdominal TN.

Simultaneous thoracic and abdominal transplantation: can we justify two organs for one recipient?

Simultaneous thoracic and abdominal (STA) transplantation is controversial because two organs are allocated to a single individual. We studied wait-list urgency, and whether transplantation led to successful outcomes. Candidates and recipients for heart-kidney (SHK), heart-liver (SHLi), lung-liver (SLuLi) and lung-kidney (SLuK) were identified through the United Network for Organ Sharing (UNOS) and outcomes were compared to single-organ transplantation. Since 1987, there were 1801 STA candidates and 836 recipients. Wait-list survival at 1- and 3 years for SHK (67.4%, 40.8%; N = 1420), SHLi (65.7%, 43.6%; N = 218) and SLuLi (65.7%, 41.0%; N = 122), was lower than controls (p < 0.001), whereas for SLuK (65.0%, 51.6%; N = 41) it was comparable (p = 0.34). All STA groups demonstrated similar 1- and 5 years posttransplant survival to thoracic controls. Compared to abdominal controls, 1- and 5 years posttransplant survival in SHK (85.3%, 74.0%; N = 684), SLuLi (75.5%, 59.0%; N= 42) and SLuK (66.7%, 55.6%; N = 18) was decreased (p < 0.01), but SHLi (85.9%, 74.3%; N = 92) was comparable (p = 0.81). In summary, STA candidates had greater risk of wait-list mortality compared to single-organ candidates. STA outcomes were similar to thoracic transplantation; however, outcomes were similar to abdominal transplantation for SHLi only. Although select patients benefit from STA, risk-exposure variables for decreased survival should be identified, aiming to eliminate futile transplantation.

The social and medical construction of lactation pathology

Beginning in the 1880s, many mothers reported breastfeeding difficulties. Doctors blamed the stress of urban life. The "bad" human milk invariably produced by the mammary glands of urban women, some physicians charged, harmed babies as surely as the dirty and adulterated cow's milk common to the late nineteenth-century city. Mothers and pediatricians proved unusually susceptible to believing this allegation. Mothers, just learning about the germ theory of disease and anxious about protecting their babies from unseen microbes, found themselves gratefully relying on "scientific" food rather than on their own, apparently faulty, bodies. And pediatricians no longer had to defend their new specialty. Now they could point to the need for improved artificial food-given women's growing inability to lactate-as one justification for their specialty's existence. Under the influence of these mothers and doctors, the notion that human lactation is an unreliable body function became a cultural truth that has persisted unabated to the present day.

Muscle spindle reinnervation following phenol block

Infusion of phenol into peripheral nerves is used clinically to manage spasticity. It produces relief of symptoms by chemical denervation. We simulated the clinical procedure by bathing the lateral plantar nerve of rats in 7% phenol solution for 20 min. We studied the innervation of muscle spindles in the plantar lumbrical muscles of untreated rats and in rats 4 and 6 weeks after a single phenol block. Spindles were identified by the immunoreactivity of nuclear bag(1) fibers to slow tonic myosin (antibody ALD 19). The integrity of the sensory and motor reinnervation of spindles was evaluated using a monoclonal antibody specific for a high molecular weight neurofilament protein. Four weeks after phenol block, muscle spindles were difficult to find, as their immunoreactivity to antibody ALD 19 was reduced. In those spindles studied, most (>80%) were completely denervated. The remainder of which were innervated by afferents only. None received efferent (gamma) innervation. After 6 weeks, spindles were readily identified and nearly all (>90%) received recognizable afferent innervation. A much smaller number (38%) received gamma innervation. Phenol block thus results in a complete denervation of muscle spindles, followed by a fairly rapid sensory reinnervation. Reinnervation by gamma motor neurons is either incomplete or significantly delayed.

4-Bromomethyl-7-methoxycoumarin and analogues as derivatization agents for high-performance liquid chromatography determinations: a review

A major part of modern analytical problem solving deals with the trace level determination of organic compounds and contaminants in biomedical, food and environmental samples. In the analysis of these samples chromatographic techniques play a predominant role. Unfortunately, however, even the combined force of an efficient separation plus a sophisticated mode of detection does not always create sufficient selectivity and/or sensitivity for the final goal to be attained. In such cases, special attention has to be devoted to derivatization or conversion of the analyte(s) of interest (for improved detection selectivity and/or sensitivity) and sample pretreatment (for trace enrichment and clean-up). The above is especially true when, as is often the case today, relatively polar drugs, endogenous compounds, additives or environmental pollutants and/or their (bio)-degradation products have to be determined. For such classes of compounds high-performance column liquid chromatography (HPLC) generally is the preferred method of separation. Reversed-phase HPLC with fluorescence detection is a powerful means of analysis for compounds which possess native fluorescence. They are, however, relatively few in number. In order to make the method useful for a much wider range of analytes, one can therefore resort to derivatization (labelling) or other means of analyte conversion to obtain highly fluorescent reaction products, which can then be detected with the required selectivity and sensitivity. 4-Bromomethyl-7-methoxycoumarin is often used as fluorescent label for the determination of compounds possessing a carboxylic group. About 8% of the biologically interesting analytes--ranging from polar amino acids and peptides to apolar fatty acids--possess such a group.(ABSTRACT TRUNCATED AT 250 WORDS)

Automated precolumn fluorescence labelling by carbodiimide activation of N-acetylaspartate and N-acetylaspartylglutamate applied to an HPLC brain tissue analysis

An automated method is described to couple carboxyl-containing metabolites to the fluorophore 2-aminoanthracene in aqueous solution (containing 75% methanol) in the presence of N,N-dicyclohexylcarbodiimide. The reaction was optimized for N-acetylaspartate (N-Ac-Asp) and N-acetylaspartylglutamate (N-Ac-Asp-Glu). The reactions occurred within 5 min at room temperature in the presence of 0.5-2 mM HCl. At concentrations of electrolytes exceeding 10 mM the coupling reaction became suboptimal. Derivatization was performed in a commercial precolumn derivatization unit. Additional tubing was needed to provide the reagents prior to reversed-phase HPLC and fluorescence detection. The assay is linear over at least three orders of magnitude; as little as 1 pmol could reproducibly be assayed in 100 micrograms wet weight brain tissue extracted with a mixture of methanol and 4 mM HCl (9:1, v/v). N-Ac-Asp and N-Ac-Asp-Glu levels in several brain regions and spinal cord were similar to those so far reported. The compounds could not be detected in peripheral tissue. The advantages, prospects and limitations of the present approach over existing methods to estimate water-soluble carboxylic acids is discussed.

The extracellular concentration of the anti-epileptic drug valproate in the rat brain as determined with microdialysis and an automated HPLC procedure

The cellular and extracellular brain concentration of valproic acid in freely moving rats has been estimated after intravenous injection of sodium valproate. Some rats were provided with a stereotaxically implanted dialysis probe in the striatum and a cannula in the heart through which the drug was injected and which allowed regular removal of blood. In other rats tissue levels of valproic acid were determined 5 and 90 min after drug injection. Valproic acid was determined by an automated precolumn derivatization procedure followed by HPLC separation and fluorimetric detection. Extracellular concentration was proportional to the blood concentration at every time interval, indicating rapid exchange of the drug between the two compartments. About 50% of the striatal content of valproate was in extracellular space. The experiments demonstrated the usefulness of microdialysis to estimate both the extracellular concentration and the average cellular drug levels, provided a sensitive analysis procedure is available.

Automated solid-phase catalyzed pre-column derivatization of fatty acids for reversed-phase high-performance liquid chromatographic analysis with fluorescence detection

A method is described to automate the solid phase catalyzed reaction of a carbonyl group with labels containing a bromomethyl group. The acids to be determined must be soluble in an aprotic, non-aqueous reaction medium, such as acetonitrile. Special emphasis is placed on the solubility of the base, which serves as a catalyst. A suspension of potassium carbonate was prepared in acetonitrile. In this way, the effective surface area of the base is drastically enlarged resulting in faster reaction kinetics. The procedure is illustrated with the detection of fatty acids in serum and rat brain tissue with bromomethylmethoxycoumarin as label. The generality of our approach for HPLC determination of carbonyl compounds is discussed.

Primary structure of O- and N-glycosylic carbohydrate chains derived from murine submandibular mucin (MSM)

The carbohydrate moiety of mouse submandibular mucin (MSM) contains mainly D-mannose and 2-acetamido-2-deoxy-D-glucose together with sialic acid, D-galactose, and 2-acetamido-2-deoxy-D-galactose. O-Glycosylically bound saccharides, obtained by treatment of MSM with alkaline borohydride, were shown by methylation analysis to have the structure: alpha-NeuAc-(2----3)-beta-Gal-(1----3)-GalNAc-ol. N-Glycosylically bound saccharides obtained from MSM by hydrazinolysis, and analysed by 500-MHz 1H-n.m.r. spectroscopy, were shown to have the following comprehensive structures. (Formula: see text).

HPLC detection of choline and acetylcholine in serum and urine by an immobilized enzyme reactor followed by chemiluminescence detection

A method using HPLC has been developed for the detection of choline (Ch) and acetylcholine (ACh) using an immobilized enzyme reactor which converts Ch and ACh into hydrogen peroxide and betaïne. The formed H(2)O(2) is quantified by means of a solid-state peroxyoxalate chemiluminescence detector based on an immobilized fluorophore and addition of oxalate from a solid bed. The conditions necessary for chemiluminescence detection are obtained by using a make-up flow of acetonitrile after the enzyme reactor. Precipitation problems due to the poor solubility of salts in the final acetonitrile-water mixture are circumvented by adding a crown ether to the make-up flow. The reproducibility of the method was calculated to be 3.4-3.7% RSD. Detection limits are in the sub-picomole range and a linear range of at least three orders of magnitude is found. Measurements in urine and serum reveal no matrix effects.

Distance and contacts: interactions of black urban elderly adults with family and friends

Distance is the major factor determining the frequency of social interaction with family and friends for elderly whites. Age, sex, marital status, length of residence, and income also affect the number of social contacts. These relationships have not been studied for elderly blacks. Utilizing data from a survey of 655 black urban residents 60 years old and older, this study investigated contacts with family and friends. The major finding was that the neighborhood is an important place for socializing with both family and friends for this population as is the case for working-class white elderly adults. A surprising finding is that, whereas social contacts increase with higher income for working-class elderly whites, for these black elderly adults who are of the working class and poor, social contacts decrease with higher income.

Access of the black urban elderly to medical care

Access to medical care of 492 black urban respondents 60 years of age and older was measured in a house-to-house survey in a large midwestern city. Of those in this study, 93 percent indicated that they had a regular source of medical care, and 88 percent reported a visit to a physician or clinic within the past year. These percentages are higher than those reported for the general population of elderly people in the United States. Physical limitation, general health, and mental health were related to access to medical care. Respondents who reported poorer physical and mental health were more likely to have a regular source of care and to have seen a physician in the past year.

Purification and partial characterization of the carbohydrate structure of lysosomal N-acetyl-beta-D-hexosaminidases from bovine brain

1. The lysosomal forms A and B, and an intermediate form I of N-acetyl-beta-D-hexosaminidase (EC 3.2.1.30) were isolated from bovine brain, resulting in the following purification factors and specific activities: hexosaminidase A 20255, 103 U mg-1; hexosaminidase B 34715, 134 U mg-1; hexosaminidase I 15241, 78 U mg-1. 2. The molecular weights of the polypeptide chains were identical for each isoenzyme: two bands of 50 and 53 k daltons were found. 3. Carbohydrate analysis showed the presence of mannose, galactose, N-acetylglucosamine and sialic acid. This composition, and the absence of N-acetylgalactosamine, indicated that only N-glycosidically linked oligosaccharide chains are present. 4. The amino-acid composition showed no substantial differences for the three isoenzymes.