Incidence and outcomes of humeral fractures in the older person

Humeral fractures are not well understood and thus we examined the incidence and outcomes of elderly humeral fractures at a single institution over a 3-year period. We found increasing incidence in humeral fractures with increasing age and negative outcomes comparable to hip fractures.

INTRODUCTION

In this study, we report the incidence of humeral fractures in the older patient and their outcomes, including new nursing homes discharges and mortality, residing in the metropolitan referral area of a Sydney tertiary referral hospital.

METHODS

All admissions between 2013 and 2016, of patients aged 65 years or more, presenting to hospital with humeral fractures were reviewed. The data was explored primarily for outcomes (mortality and new admissions to residential aged care facility) and secondarily for clinical association with humeral fractures.

RESULTS

Two hundred eighty-one episodes of humeral fracture were identified. Incidence peaked in the above 85-year-old group at 670 per 100,000 persons per year. Proximal fractures were accounted for 84.3% of the cohort. 12.8% received operative management. The in-hospital mortality rate was 3.6%. Gender was a significant predictor for mortality (OR = 5.8, 95% CI 1.3-28.5, p value = 0.0032) with males six times more likely to experience in-hospital mortality compared to females. 17.8% of participants were admitted to a new nursing home. Logistical regression demonstrated age (OR = 1.10, 95% CI 1.04-1.17; p value = 0.001) and Charlson comorbidity index (OR = 1.32, 95% CI 1.04-1.66; p value = 0.02) were predictors of admission to a new nursing home.

CONCLUSION

Humeral fractures are common in the older population and cause a substantial amount of new nursing home admissions and mortality. Further study is required to ascertain appropriate guidelines for treatment and rehabilitation.

Impact of preoperative body mass index on the final outcome after laparoscopic sleeve gastrectomy for morbid obesity

OBJECTIVE

Laparoscopic sleeve gastrectomy (LSG) is a popular bariatric surgery due to its excellent results and limited morbidity. Our study aims to assess the efficacy of LSG in terms of loss of weight and co-morbidity improvement and to evaluate the impact of preoperative body mass index (BMI) on the final outcome.

MATERIAL AND METHODS

The data of 173 patients who underwent LSG were analyzed. Laparoscopic sleeve gastrectomy was indicated only for patients with BMI >40. Mean postoperative BMI, co-morbidity improvement, operative data and complications, length of hospital stay and excess weight loss were evaluated and recorded.

RESULTS

This study included 151 females and 22 males with a mean age of 37.6 years. Patients were divided into two groups according to their BMI (group I <50, group II >50). Mean preoperative BMI was 53.8 kg/m2. Mean operative time was 120 minutes. Mean duration of hospital stay was 3.2 days. Mean postoperative BMI decreased to 47.3 kg/m2 at 1 year. Excess weight loss was 43.1% at 6 months, 71.1% at 1 year, and 87.5% at 5 years. Group I showed a significantly shorter length of hospital stay, more improvement of laboratory parameters and more reduction in BMI as compared to group II. There was one mortality and six cases had gastric staple line leakage.

CONCLUSION

Laparoscopic sleeve gastrectomy is an efficient treatment to achieve significant weight loss that is maintained up to 5 years of follow up, also it improves some of the obesity related co-morbidities. This beneficial impact of LSG appears to be significantly higher in patients with BMI <50.

Chronic Mastitis in Egypt and Morocco: Differentiating between Idiopathic Granulomatous Mastitis and IgG4-Related Disease

Idiopathic granulomatous mastitis (IGM) is a benign, frequently severe chronic inflammatory lesion of the breast. Its etiology remains unknown and reported cases vary in their presentation and histologic findings with an optimal treatment algorithm yet to be described owing mainly to the disease's heterogeneity. IgG4‐related disease (IgG4‐RD) is a newly recognized systemic fibroinflammatory condition characterized by a dense lymphoplasmacytic infiltrate with many IgG4‐positive plasma cells, storiform fibrosis, and obliterative phlebitis. Immunosuppressive therapy is considered to be an effective first‐line therapy for IgG4‐RD. We sought to clarify and classify chronic mastitis according to the histologic findings of IgG4‐RD mastitis with respect to IGM and to develop a robust diagnostic framework to help select patients for optimal treatment strategies. Using the largest collection to date (43 cases from Egypt and Morocco), we show that despite sharing many features, IGM and IgG4‐RD mastitis are separate diseases. To diagnostically separate the diseases, we created a classification schema—termed the Michigan Classification—based upon our large series of cases, the consensus statement on IgG4‐RD, and the histologic description of IGM in the literature. Using our classification, we discerned 17 cases of IgG4‐RD and 8 cases of IGM among the 43 chronic mastitis cases, with 18 indeterminate cases. Thus, our Michigan Classification can form the basis of rational stratification of chronic mastitis patients between these two clinically and histopathologically heterogeneous diseases.

Single incision transumbilical laparoscopic varicocelectomy versus the conventional laparoscopic technique: A randomized clinical study

BACKGROUND

Varicocele is the most common correctable cause of infertility. We analyzed the outcomes of single incision laparoscopic varicocelectomy (SIL-V) in comparison with conventional transperitoneal varicocelectomy (CTL-V).

METHODS

Patients with clinically palpable varicocele treated by laparoscopic varicocelectomy were randomly allocated into two groups: SIL-V and CTL-V group. The primary outcome measures were improvement in semen parameters and resolution of testicular pain. Secondary outcome measures included operating time, postoperative pain scores, time to return to normal activity, patient satisfaction and postoperative complications.

RESULTS

Eighty patients completed the study. No vascular or intestinal complications occurred during both procedures. All patients were discharged 24 h postoperatively. The parameters measuring the success of varicocelectomy had improved for the majority of patients with no significant difference between the two groups. There was significantly longer operating time in SIL-V group (44.6 ± 5.4 min) than in CTL-V group (41.3 ± 8.5 min) (P = 0.03). The difference in operating time was lost when bilateral procedures were compared (P = 0.21). The mean VAS scores for pain at 3, 24 and 48 h postoperatively were significantly lower in SIL-V group (P = 0.02, P = 0.03 and P < 0.001 respectively). Time to return to normal activity was significantly shorter in SIL-V (P < 0.001). Patient satisfaction was significantly higher in SIL-V group (P < 0.01). Postoperative complications were comparable in both groups.

CONCLUSION

SIL-V is a safe and effective straightforward alternative to the well-established and accepted CTL-V. The tendency toward decreased postoperative pain, rapid return to normal activity and the high patients' satisfaction rate regarding cosmetic results are potential benefits of SIL-V procedure.

CLINICAL TRIAL

(NCT02335385).

Unilateral sequential endoscopic thoracic sympathectomy for palmar hyperhidrosis: a proposed technique to overcome compensatory hyperhidrosis and improve plantar hyperhidrosis

BACKGROUND

Although endoscopic thoracic sympathectomy (ETS) offers permanent cure of palmar hyperhidrosis (PH), compensatory hyperhidrosis (CH) often complicates the procedure. We analyzed the outcomes of a 2-month interval for unilateral sequential ETS (S-ETS) in comparison with simultaneous bilateral ETS (B-ETS), notably regarding CH and associated plantar hyperhidrosis, in treating patients with PH.

PATIENTS AND METHODS

Four hundred seven patients with intractable PH were randomly assigned into two groups: the B-ETS group (204 patients) and the S-ETS group (203 patients).

RESULTS

Three hundred sixty-four patients completed the study. Complication rates were comparable for both groups. No patient died perioperatively, and no conversion was necessary. Treatment success on follow-up was 97.2% for S-ETS and 96.7% for B-ETS. The incidence of CH was decreased substantially from 131 (71.1%) patients in the B-ETS group to 22 (12.2%) patients in the S-ETS group (P<.001), with no patient suffering severe CH in the S-ETS group compared with 33 (25.5%) patients in the B-ETS group. Eighty-four (58.3%) patients in the S-ETS group had simultaneous disappearance or decreased perspiration on the soles. All patients in the S-ETS group were satisfied, whereas 37.9% of B-ETS patients were unsatisfied with their operation, mostly because of CH and recurrences.

CONCLUSIONS

Although both sympathectomies were effective, safe, and minimally invasive methods for treatment of PH, unilateral sequential ETS appeared to be a more optimal technique in terms of reduction of CH to a minimum and improvement of associated plantar hyperhidrosis.

Abstract 4977: Chronic mastitis in North Africa: Geographic overlap and a potential precursor comorbidity of inflammatory breast cancer

North African countries, such as Egypt and Morocco, have a high prevalence of non-infectious, chronic mastitis (up to 10% of patients presenting with breast problems) compared to less than 1% worldwide. This same geographic region also suffers from an unusually high prevalence of inflammatory breast cancer (IBC) - 10-15% of breast cancer cases - versus just 1-2% of cases in the U.S. IBC is a serious public health issue as it is the most lethal form of breast cancer because of the propensity for rapid onset of disseminated metastases, which are present in one-third of cases at diagnosis. It is our hypothesis that this geographic overlap is not coincidental, but that the high level of background chronic breast inflammation changes the mammary microenvironment making it more auspicious for the development of IBC. Here we report our work aimed at determining molecular and histologic criteria to classify mastitis into pathogenic groups in order to rationally guide treatment for this serious inflammatory illness, as well as study its possible role in the development of IBC.

We identified 44 cases of chronic mastitis of unknown etiology. Cases were defined as any female patient with histopathological diagnosis of chronic mastitis seen at the 5 study hospitals in Egypt and Morocco from 2008-2011. Exclusion criterion was previous diagnosis of malignancy. Biopsy slides were analyzed by a pathologist and stained for IgG4 and IgG. Out of the 44 cases of chronic mastitis using consensus guidelines and our molecular IgG4 profiling, we identified 10 as idiopathic granulomatous mastitis (IGM) and 17 as breast manifestations of IgG4-related disease. IGM is a rare non-neoplastic, chronic, often severe inflammatory lesion of the breast that mimics carcinoma clinically and radiologically. Treatment strategies include watchful waiting, immunosuppressive therapy, wide local or other excisions, or combinations of the above. IgG4-related disease is a newly recognized fibro-inflammatory condition. It is characterized by the formation of tumefactive lesions, a dense lymphoplasmacytic infiltrate with many IgG4-positive plasma cells, storiform fibrosis, obliterative phlebitis and, frequently, elevated serum IgG4 concentrations. While no randomized clinical trials have been conducted, glucocorticoid treatment is the standard first line therapy and appears to be quite effective in the majority of patients.

This series is the largest reported and is the first step toward changing the chronic breast inflammatory landscape in North Africa by classifying the chronic mastitis into pathogenic groups that can guide personalized treatment protocols. Further studies are needed to discern whether effective and timely treatment of these chronic inflammatory conditions may lower the incidence of IBC.

Citation Format: Steven G. Allen, Hanna Oltean, Kathy Toy, Omar S. Omar, Tamer Youssef, Mehdi Karkouri, Azza Abdel-Aziz, Ahmad Hablas, Ali Tahri, Celina Kleer, Amr Soliman, Sofia D. Merajver. Chronic mastitis in North Africa: Geographic overlap and a potential precursor comorbidity of inflammatory breast cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4977. doi:10.1158/1538-7445.AM2014-4977

Association of the CagA gene positive Helicobacter pylori and tissue levels of interleukin-17 and interleukin-8 in gastric ulcer patients

It has been reported that CagA gene positive Helicobacter pylori (CagA+ H. pylon) induces severe gastric mucosal inflammation. On the other hand, Interleukin (IL)-17 is known to stimulate IL-8 release by the gastric epithelial cells which facilitates chemotaxis of neutrophils through an IL-8-dependent mechanism. The aim of the study is to determine the role of IL-17 and IL-8 in the development of gastritis and gastric ulcer in H. pylori infected patients. Mucosal biopsy samples were obtained from the ulcer site of gastric mucosa of 28 patients with gastric ulcer (GU), 27 with gastritis and 8 controls subjects without gastritis or ulcers. Infection with H. pylori of patients and controls was assessed by a rapid urease test, histological examination and culture. Measurement of the tissue levels of IL-17 and IL-8 were assayed by ELISA. H. pylori cagA gene was assessed by polymerase chain reaction (PCR). Out of the 28 patients with GU, 18 (64.2%) patients were positive for H. pylori infection, while 13 (48.1%) patients with gastritis and none of the controls were positive for H. pylori infection The CagA gene was detected in 12 (66.6%) in H. pylori GU patients, and 7 (53.8%) H. pylori positive gastritis. IL-17 was significantly higher in GU-CagA+ve H. pylori compared to GU-CagA- H. pylori (P <0.05), while IL-8 showed no significant difference between groups. The mean levels of IL-8 in gastritis-CagA+ H. pylori) was significantly higher compared to gastritis--CagA- H. pylori- (P <0.05). IL-17 showed significant association with the number of neutrophils in both GU and gastritis (r = 0.689, P < 0.05 & r = 0.618, P < 0.05). Also, IL-8 showed significant association with the number of neutrophils in both GU and gastritis n (r = 0.468, P < 0.05 & r = 0.727, P < 0.05). It is concluded that the Cag+ve H. pylori is associated with induction of mucosal injury. Also, IL-8 and IL-17 plays a role in the development of GU and gastritis especially in CagA+ H. pylori.

Intraoperative parathyroid hormone as an indicator for parathyroid gland preservation in thyroid surgery

BACKGROUND

Intra-operative parathyroid hormone (PTH) levels have successfully been used to assess surgical ablation of parathyroid adenomas, the use of this same test to predict preservation of viable gland has not been widely used.

AIM

to test the sensitivity and specificity of intraoperative rapid PTH assay test in predicting permanent postoperative hypoparathyroidism, and applicability to guide the search for inadvertently removed parathyroid glands for possible auto transplantation.

PATIENTS AND METHODS

52 patients undergoing total thyroidectomy for non-malignant thyroid diseases were included. Intraoperative rapid PTH assay test was performed. If levels were reduced, or less than 3 parathyroid glands were detected, removed thyroid gland was examined for unintentionally removed parathyroid tissue for possible auto transplantation.

RESULTS

There was a strong correlation between intraoperative rapid PTH assays and those taken 24 hours after surgery, 16 out of 52 patients had reduction of the PTH intraoperatively to levels below 25 pg/ml, of them, 11 patients (who had values between 15-24 pg/ml) recovered to normal PTH levels within 4 weeks, while the 5 patients with intraoperative PTH levels below 15 pg/ml failed to regain normal PTH levels up to 12 weeks postoperatively, even in those patients where parathyroid tissue was auto transplantated. The 4 patients who had parathyroid tissue reimplanted intraoperatively restored some of their parathyroid function as indicated by relative rise of their PTH levels, but did not reach even the low normal levels. (ROC) curve for prediction of early hypoparathyroidism using intraoperative rapid PTH assay was statistically highly significant with optimal cutoff value for predicting early hypocalcaemia level <27 pg/ml, (sensitivity 100%, specificity 68.2%). (ROC) curves for predicting permanent hypoparathyroidism using intraoperative rapid PTH assay or standard PTH assay taken 24 hours after surgery were statistically significant with optimal cutoff value PTH level <12 pg/ml on the intraoperative PTH curve or <15 pg/ml on the postoperative PTH curve (sensitivity 100%, specificity 100%).

CONCLUSION

Intraoperative PTH assay may allow intraoperative monitoring of parathyroid function, predicting postoperative outcomes, may identify patients at risk of developing postoperative hypoparathyroidism, guiding surgeons to re-examine removed specimens for inadvertently removed parathyroid tissue with possible auto transplantation, or more practically a guide to early replacement therapy to prevent hypocalcaemia, leading to safe and early hospital discharge. Limitations in our study to be reconsidered in further studies, are relative small sample size, inability for randomisation, and the variable values reported for the cut off value of PTH causing hypocalcaemic symptoms needing intervention.

Combined transoral-transnasal approach in the repair of congenital posterior choanal atresia: clinical experience

BACKGROUND

A myriad of techniques have been described for managing posterior choanal atresia over the years, yet no standardized surgical protocol has been established.

OBJECTIVE

To present our experience with the transoral-transnasal approach for repairing posterior choanal atresia.

PATIENTS AND METHODS

A prospective study of children with posterior choanal atresia treated at Ain Shams University Hospitals from 2006 to 2010. Thirteen children affected by this malformation underwent a transoral-transnasal approach by the authors using a standardized surgical technique. All patients were followed up for a period ranging from 6 months to 3 years. Stents were used in neonates, and topical mitomycin C was applied in follow-up when cases needed further dilatation after the first intervention.

RESULTS

Patient demographics were obtained. Stents were used in 11 cases, and mitomycin C was used in 9 cases. Complications were as follows: 1 case had palatal perforation that healed spontaneously, 2 cases had restenosis and were lost to follow-up, and of the other 11 cases, 3 needed no further management and 8 cases needed further dilatation.

CONCLUSION

The aforementioned combined transoral-transnasal technique provides a good alternative for managing posterior choanal atresia with easier, four-handed surgery to ensure adequate posterior choana for nasal breathing, but it usually needs multiple sessions.

Bariatric surgery: Rhabdomyolysis after open Roux-en-Y gastric bypass: a prospective study

BACKGROUND

Rhabdomyolysis (RML) is a recently recognized complication of bariatric surgery (BS). The aim of this prospective study was to determine frequency, risk factors, and clinical relevance of RML in morbidly obese patients treated with open Roux-en-Y gastric bypass (RYGBP).

METHODS

A total of 23 consecutive patients with morbid obesity undergoing primary open RYGBP were included prospectively in the present study. The following parameters were recorded: age, gender, BMI (kg/m(2)), comorbidities (presence of known hypertension and diabetes), duration of surgery, levels of serum creatine phosphokinase (CPK) measured before surgery and daily after until the values were clearly tending towards normal, and the presence of neuromuscular symptoms in the early post-operative period. RML was defined as post-operative CPK >1000 IU/l (5 times the normal value). Patients were divided into two groups according to the presence or absence of RML.

RESULTS

The study sample consists of 16 females (69.6%) and 7 males (29.4%). RML was diagnosed in 7 (30.4%) patients with CPK levels greater than 5000 IU/l in 3 patients (42.9%). BMI was identified as an independent risk factor for RML (P = 0.031). The best cut-off value of BMI as a predictor of RML was 55.88 kg/m(2) giving sensitivity of 100% and specificity of 80.7%. Other variables (age, sex, comorbidities, and duration of surgery) did not have a significant predictive effect on the rate of RML.

CONCLUSION

After open bariatric surgery with RYGBP, the risk of RML increases in obese patients specially when BMI >56 kg/m(2). In such patients, CPK, which is an inexpensive easily done test, should be performed routinely to guarantee early diagnosis and consequently preventive treatment of RML complications.

Comparative study between botulinum toxin injection and partial division of puborectalis for treating anismus

OBJECTIVES

The objective of this study was to compare the results of partial division of puborectalis (PDPR) versus local botulinum toxin type A (BTX-A) injection in treating patients with anismus.

PATIENTS AND METHODS

This prospective randomized study included 30 male patients suffering from anismus. Diagnosis was made by clinical examination, barium enema, colonoscopy, colonic transit time, anorectal manometry, balloon expulsion test, defecography, and electromyography. Patients were randomized into: group I which included 15 patients who were injected with BTX-A and group II which included 15 patients who underwent bilateral PDPR. Follow-up was conducted for about 1 year. Improvement was considered when patients returned to their normal habits.

RESULTS

BTX-A injection achieved initial success in 13 patients (86.7%). However, long-term success persisted only in six patients (40%). This was in contrast to PDPR which achieved initial success in all patients (100%) with a long-term success in ten patients (66.6%). Recurrence was observed in seven patients (53.8%) and five patients (33.4%) following BTX-A injection and PDPR, respectively. Minor degrees of incontinence were confronted in two patients (13.3%) following PDPR.

CONCLUSION

BTX-A injection seems to be successful for temporary treatment of anismus.

Comparative study between biofeedback retraining and botulinum neurotoxin in the treatment of anismus patients

PURPOSE

Anismus is a significant cause of chronic constipation. This study came to revive the results of BFB training and BTX-A injection in the treatment of anismus patients.

MATERIALS AND METHODS

Forty-eight patients with anismus (33 women; mean age 39.6 +/- 15.9) were included in this study. All patients fulfilled Rome II criteria for functional constipation. All patients underwent anorectal manometry, balloon expulsion test, defecography, and electromyography (EMG) activity of the EAS. All patients had non-relaxing puborectalis muscle. The patients were randomized into two groups. Group I patients received biofeedback therapy, two times per week for about 1 month. Group II patients were injected with BTX-A. Follow-up was conducted weekly in the first month then monthly for about 1 year.

RESULTS

In the BFB training group, three patients quit before the end of sessions with no improvement; initial improvement was recorded in 12 patients (50%) while long-term success was recorded in six patients (25%). In the BTX-A group, clinical improvement was recorded in 17 patients (70.83%), but the improvement persisted only in eight patients (33.3%). There is a significant difference between BTX-A group and BFB group regarding the initial success, but this significant difference disappeared at the end of follow-up. Manometric relaxation was achieved significantly post-BFB and post-BTX-A injection with no significant difference between the two groups.

CONCLUSIONS

Biofeedback training has a limited therapeutic effect on patients suffering from anismus. BTX-A injection seems to be successful for temporary treatment of anismus.

Effect of Helicobacter pylori eradication on ulcer recurrence after simple closure of perforated duodenal ulcer

BACKGROUND

This study was conducted to elucidate the prevalence of Helicobacter pylori in patients with a perforated duodenal ulcer and to determine whether eradication of H. pylori prevent ulcer recurrence following simple repair of the perforation.

PATIENTS AND METHOD

Eighty-three patients with perforated duodenal ulcer (68 males); mean age was 47.8 years+/-7.2. Antral mucosal biopsies (to determine the status of HP by rapid urease test, culture and histological examination/staining) were obtained during laparotomy by passing a biopsy forceps through the perforation site. H. pylori positive patients who had undergone patch repair were randomized into the eradication group who received amoxicillin, metranidazole plus omperazole and the control group was given omeprazole alone. Follow-up endoscopy and antral biopsies were performed at 8 weeks, 16 weeks and 1 year to show ulcer healing and determine H. pylori state.

RESULTS

Of 77 patients in the study, 65 patients (84.8%) had H. pylori. These patients were randomly divided into the triple therapy group (34 patients) and the control group (31 patients). Eradication of H. pylori was significantly higher in the triple therapy group than the control group and initial ulcer healing was significantly better in the eradication group. After 1 year, ulcer recurrence was (6.1%) in the eradication group vs. (29.6%) in the control group (P=0.001).

CONCLUSION

H. pylori was present in a high proportion of patients with duodenal ulcer perforation. Eradication of H. pylori after simple closure of a perforated duodenal ulcer reduced the incidence of recurrent ulcer.

Laparoscopic versus open cholecystectomy in cirrhotic patients: a prospective randomized study

BACKGROUND

Improved laparoscopic experience and techniques have made laparoscopic cholecystectomy (LC) feasible options in cirrhotic patients. This study was designed to compare the risk and benefits of open cholecystectomy (OC) versus LC in compensated cirrhosis.

METHOD

A randomized prospective study, in the period from October 2002 till December 2006, where 110 cirrhotic patients with symptomatic gallstone were randomly divided into OC group (55 patients) and LC group (55 patients).

RESULTS

There was no operative mortality. In LC group 4 (7.33%) patients were converted to OC. Mean surgical time was significantly longer in OC group than LC group (96.13+17.35 min versus 76.13+15.12) P<0.05, associated with significantly higher intraoperative bleeding in OC group (P<0.01), necessitating blood transfusions to 7 (12.72%) patients in OC group. The time to resume diet was 18.36+8.18 h in LC group which is significantly earlier than in OC group 47.84+14.6h P<0.005. Hospital stay was significantly longer in OC group than LC group (6+1.74 days versus 1.87+1.11 days) P<0.01 with low postoperative morbidity.

CONCLUSION

LC in cirrhotics is still complicated and highly difficult which associates with significant morbidity compared with that of patients without cirrhosis. However, it offers lower morbidity, shorter operative time; early resume dieting with less need for blood transfusion and reducing hospital stay than OC.

Safety profile of the intravitreal streptokinase-plasmin complex as an adjunct to vitrectomy in the rabbit

BACKGROUND

The generation of an atraumatic posterior vitreous detachment (PVD), a common goal in vitreoretinal surgery, is a challenge, particularly in children and young trauma patients. Plasmin has been proposed as an adjunct to vitrectomy to enzymatically generate a PVD. Low doses of streptokinase-activated plasmin were tested in human pilot studies. This dose-escalation study assesses the safety range of intravitreal human streptokinase-plasmin in rabbits.

METHODS

Plasminogen was isolated from human plasma by affinity chromatography, followed by activation with streptokinase (1:1), to generate the streptokinase-plasmin complex. Enzyme doses from 0.1-7 activity units (AU, in 0.1 ml) were injected into the mid-vitreous of 35 eyes; six control eyes were injected with balanced salt solution (BSS, 0.1 ml). Thirty minutes after injection, a two-port vitrectomy was performed. Fundus and slit lamp examinations were performed on days 1 and 7. On days 2 and 7, bright flash electroretinography was performed and compared with preoperative recordings. Some animals receiving higher doses of streptokinase-plasmin (1-7 AU) were followed clinically and with electroretinography for up to 9 months.

RESULTS

A mild-to-moderate inflammatory response was seen in both control and plasmin-treated eyes on day 1, but had disappeared completely by day 7 in most eyes. In the 7 AU group, inflammation was stronger and more protracted. Two of three eyes from this group developed wrinkling of the medullary rays; one of them showed discoloration and traction at the medullary rays in the late follow-up. Electroretinograms (ERGs) of vitrectomized control eyes showed the following changes from preoperative values: 48 h, a-wave -11.10% [no significant (n.s.)], b-wave -14.62% (P=0.046); 7 days, a-wave +9.18% (n.s.), b wave +11.69% (n.s.). For the enzyme-treated eyes: 48 h: a-wave -20.43% (P<0.001), b-wave -9.57% (p<0.001); 7 days: a wave -14.21% (P<0.001), b-wave +2.48% (P<0.001). There was no evidence of dose-dependent ERG changes in enzyme-treated eyes at doses up to 5 AU. Groups of up to 3 AU were investigated by light and transmission electron microscopy, without evidence of toxicity.

CONCLUSION

Streptokinase-plasmin doses up to 3 AU were found to be safe when injected into rabbit eyes followed by vitrectomy.

Salt secretion and stomatal behaviour in Avicennia marina seedlings fumigated with the volatile fraction of light Arabian crude oil

Seedlings of the salt secreting mangrove Avicennia marina were exposed to fumes of the volatile fraction of light Arabian crude oil (VFCO) under controlled conditions. Rates of salt secretion were determined in leaves fumigated for 0, 3, and 6 h under four different salinity levels (10, 20, 30, and 40 ppt). Studying the effect of these fumigation periods on stomatal resistance and transpiration was restricted to one salinity level (20 ppt). Opposite to salinity, increasing the fumigation period significantly reduced both salt secretion and transpiration with a significant increase in the stomatal resistance to gas diffusion. During the first day of recovery from fumigation stress, different stomatal oscillation patterns were observed in the treated plants. The amplitude of the oscillations increased with the duration of fumigation. as did the time required for stomatal recovery. Seedlings fumigated for 3 h started to recover within 48 h, while full recovery in seedlings fumigated for 6 h required almost twice that period. The apparent recovery process was evident in the damping off of the amplitude of stomatal oscillations during the measurements period. Data presented herein show that the exposure of mangrove seedlings to VFCO disturbs the normal functions of two major structures in the leaves, i.e. the stomata and the salt glands. The ecophysiological significance of these results was discussed in relation to previous studies.

Evidence for oxidative activation of c-Myc-dependent nuclear signaling in human coronary smooth muscle cells and in early lesions of Watanabe heritable hyperlipidemic rabbits: protective effects of vitamin E

BACKGROUND

Oxidized LDL (oxLDL) promotes atherogenesis, and antioxidants reduce lesions in experimental models. OxLDL-mediated effects on c-Myc are poorly characterized, and those on c-Myc nuclear pathways are completely unknown. c-Myc stimulates smooth muscle cell (SMC) proliferation and could be involved in atherosclerosis. We investigated the early effects of oxLDL and alpha-tocopherol on c-Myc, its binding partner Max, and the carboxy-terminal domain-binding factors activator protein-2 and elongation 2 factor in human coronary SMCs. We also investigated whether 9-week treatment of Watanabe heritable hyperlipidemic (WHHL) rabbits with diet-enriched alpha-tocopherol reduces c-Myc expression and oxLDL in the left coronary artery.

METHODS AND RESULTS

OxLDL enhanced c-Myc/Max expression and transcription by cotransfection assay and the nuclear activities of E2F and activator protein-2 by binding shift and supershift in coronary SMCs. alpha-Tocopherol significantly reduced these molecular events. Furthermore, alpha-tocopherol reduced early lesions, SMC density, and the immunohistochemical presence of c-Myc, which colocalized with oxLDL/foam cells in the coronaries of WHHL rabbits.

CONCLUSIONS

We provide the first evidence that oxLDL and alpha-tocopherol may influence c-Myc activation and several c-Myc-dependent signaling pathways in human coronary SMCs. The observation that in vivo, an antioxidant reduces both c-Myc and oxLDL in early coronary lesions of rabbits is consistent with, but does not prove, the hypothesis that c-Myc-dependent factors activated by oxidative processes contribute to atherogenesis and coronary heart disease.

The uptake, location and fluorescence of hypericin in bovine intact lens

PURPOSE

To determine the uptake, location and fluorescence of hypericin, the active ingredient in St. John's Wort, in situ in the isolated intact calf lens.

METHODS

The absorption and fluorescence spectra of hypericin 10(-5 ) M were measured in DMSO/phosphate buffer, pH 7.4) [PBS] (1/10 in volume) in the presence of alpha-crystallin (0.5 and 1.1 mg/ml). Bovine lenses were incubated in the dark for 24 hours in 10(-4) M hypericin in a DMSO/PBS (1/10 in volume) mixture. Diffused hypericin fluorescence emission was detected with a fluorescence stereomicroscope from the PBS washed lens surface. A lens-holder specially built for front-surface excitation-detection was used to measure fluorescence emission and excitation spectra of intact lenses incubated with hypericin solutions.

RESULTS

As increasing concentrations of alpha-crystallin were added, the absorption and fluorescence spectra of hypericin in DMSO/PBS (1/10 in volume) changed, indicating a binding between the chromophore and the lens protein. Fluorescence emission spectra detected from the lens surface (lambda( em) = 601 and 651 nm; lambda(exc) = 550 nm) confirmed that hypericin does bind to the ocular tissues.

CONCLUSIONS

The results we obtained in simplified model systems can provide clues to investigate the effects of hypericin on lens properties in physiological conditions. Hypericin could in fact bind to lens protein thus increasing the retention time of hypericin in the eye and possibly altering a-crystallin properties as a chaperone. Should therefore hypericin be taken up by the lens, this can be detected, non-invasively by its fluorescence. Therefore, ophthalmologists may use a slit-lamp or scanning fluorometry to monitor the uptake of hypericin in the eyes of patients using St. John's Wort or receiving high doses of hypericin while undergoing photodynamic therapy.