Surgical reduction of scrotal massive localized lymphedema (MLL) in obesity.

BACKGROUND: Lymphedema of the penis and scrotum is physically and psychologically disabling. Obesity is a source of secondary lymphedema. When restricted to specific anatomical regions in obesity, this is termed massive localized lymphedema (MLL). Few surgical cases of specific scrotal MLL in obesity are reported in the literature. We present our case series to improve the management of this complicated pathology. METHODS: This is a retrospective review of obese adult patients with clinically diagnosed scrotal MLL undergoing reduction scrotoplasty by the senior author (J.R.S.) from 1992 to 2012. Medical, social, familial, surgical, and follow-up data were extracted. Prior infection of the scrotal lymphedema, surgical details, pathologic evaluation, and postoperative complications were noted. A series of the cases is presented. RESULTS: Four cases met the criteria for study. The average age was 35 years with an average body mass index of 53.9. Average resection at the first procedure was 3492 g. All patients were reconstructed with laterally based scrotal flaps. The pathology for each case was consistent with chronic lymphedema; no sarcomatous changes were noted. Fifty percent of the patients had recurrence of the scrotal MLL. The average total number of operations during the follow-up period for either complication or recurrence was two. CONCLUSIONS: This is the largest case series specifically investigating surgical treatment for scrotal MLL in obesity. Lateral-based scrotal flaps (with or without mid-raphe Z-plasty) permit anatomic reconstruction. Complications are common and recurrence is frequent after surgical management. Excision with reconstruction improves urinary function and overall symptoms.

[Pulmonary neuroendocrine neoplasms]. / Neuroendokrine Neoplasien der Lunge.

The pulmonary neuroendocrine neoplasms originate from the enterochromaffin cells which are diffusely distributed in the body. The incidence of these tumors has increased significantly in recent decades due to the available diagnostics. They make up about 1-2% of all lung tumors and 20-30% of all neuroendocrine neoplasms. The current WHO classification from 2004 divides them into typical carcinoids (TC), atypical carcinoids (AC), large cell neuroendocrine carcinomas (LCNEC) and small cell carcinomas (SCLC). The major neuroendocrine biomarkers are chromogranin A, synaptophysin and CD56. TC have a low mitotic rate of <2 mitoses/2mm(2) (10 HPF), whereas the mitotic rate of the AC is 2-10 mitoses/2 mm(2) (10 HPF). The Ki-67 staining is helpful to distinguish typical and atypical carcinoids from the highly malignant LCNEC and SCLC. Clinically, the patient presents usually with cough, hemoptysis or bronchial obstruction. The occurrence of a carcinoid or Cushing's syndrome and a tumor-associated acromegaly are rare. Surgical resection with radical lymph node dissection is the treatment of choice for achieving long-term survival. Endoscopic resection of the endobronchial tumor growth is a good alternative for inoperable endobronchially localized tumors. Peptide receptor radionuclide therapy (PRRT) is a promising treatment option for patients with metastatic or unresectable pulmonary neuroendocrine tumors. New targeted therapies using angiogenesis inhibitors, mTOR inhibitors, and tyrosine kinase inhibitors are being tested for their effectiveness in many previous studies. Typical carcinoid tumors metastasize less frequently than AC, the 5-year survival rate of patients with TC being over 90%. Patients with AC have a 5-year survival rate between 35% and 87%. The highly malignant LCNEC and SCLC, on the other hand, have a 5-year survival rate between 15% and 57%, and <5% respectively. The increasing number of therapeutic options and diagnostic procedures requires a multidisciplinary approach and decision-making in multidisciplinary tumor conferences to ensure a personalized treatment approach. Therefore patients with a neuroendocrine neoplasm of the lung should be treated in specialized centers.

Does Nebulin Make Tropomyosin Less Dynamic in Mature Myofibrils in Cross-Striated Myocytes?

Myofibrils in vertebrate cardiac and skeletal muscles are characterized by groups of proteins arranged in contractile units or sarcomeres, which consist of four major components - thin filaments, thick filaments, titin and Z-bands. The thin actin/tropomyosin-containing filaments are embedded in the Z-bands and interdigitate with the myosin-containing thick filaments aligned in A-bands. Titin is attached to the Z-band and extends upto the middle of the A-Band. In this mini review, we have addressed the mechanism of myofibril assembly as well as the dynamics and maintenance of the myofibrils in cardiac and skeletal muscle cells. Evidence from our research as well as from other laboratories favors the premyofibril model of myofibrillogenesis. This three-step model (premyofibril to nascent myofibril to mature myofibril) not only provides a reasonable mechanism for sequential interaction of various proteins during assembly of myofibrils, but also suggests why the dynamics of a thin filament protein like tropomyosin is higher in cardiac muscle than in skeletal muscles. The dynamics of tropomyosin not only varies in different muscle types (cardiac vs. skeletal), but also varies during myofibrillogenesis, for example, premyofibril versus mature myofibrils in skeletal muscle. One of the major differences in protein composition between cardiac and skeletal muscle is nebulin localized along the thin filaments (two nebulins/thin filament) of mature myofibrils in skeletal muscle cells, but which is expressed in a minimal quantity (one nebulin/50 actin filaments) in ventricular cardiomyocytes. Interestingly, nebulin is not associated with premyofibrils in skeletal muscle. Our FRAP(Fluorescence Recovery After Photobleaching) results suggest that tropomyosin is more dynamic in premyofibrils than in mature myofibrils in skeletal muscle, and also, the dynamics of tropomyosin in mature myofibrils is significantly higher in cardiac muscle compared to skeletal muscle. Our working hypothesis is that the association of nebulin in mature myofibrils renders tropomyosin less dynamic in skeletal muscle.

Feasibility and effectiveness of the NEST13+ as a screening tool for advanced illness care needs.

BACKGROUND: A comprehensive whole-person approach might improve processes and outcomes of care for patients with cancer. OBJECTIVE: To assess the ability of NEST13+ (Needs of a social nature; Existential concerns; Symptoms; and Therapeutic interaction), a screening and assessment tool, to identify social, emotional, physical, and care-system needs and to improve clinical outcomes for cancer patients in tertiary care. DESIGN, SETTING, PATIENTS: A controlled trial involving 451 patients hospitalized for cancer care at a comprehensive cancer center. INTERVENTION: Patients responded to 13 screening questions regarding possible care needs. When an individual response exceeded threshold levels, additional in-depth questions for the relevant need were asked. For patients in the intervention arm, clinical recommendations for each dimension of need were generated based on a previously developed NEST-response-driven menu, and were reported to the clinical team. MEASUREMENTS: Documented needs, clinician response, patient perception of goals alignment, and overall quality of palliative care. RESULTS: Using the NEST13+ tool in the clinical setting facilitated greater documentation of illness-related needs than routine clinical assessment. Improvement in secondary outcomes was attenuated: changes in the clinician response were modest; changes in outcomes were not significant. CONCLUSION: The NEST13+ tool facilitated identification of a wider range of important needs than traditional evaluation, while care outcomes were not improved. Traditional evaluation may need improvement. Future trials of the NEST13+ should focus on more intensive clinician-directed interventions.

Ectopic scalp replantation: a case report.

Temporary ectopic implantation with secondary replantation at the anatomic site is useful in salvage of extremities or organs [Godina M, Bajec J, Baraga A. Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg 1986;78: 295-99; Chernofsky MA, Sauer PF. Temporary ectopic implantation. J Hand Surg [Am] 1990;15:910-14; Matloub HS, Yousif NJ, Sanger JR. Temporary ectopic implantation of an amputated penis. Plast Reconstr Surg 1994;93:408-12; Hallock GG. Transient single-digit ectopic implantation. J Reconstr Microsurg 1992;8:309-11; Graf P, Groner R, Horrl W. Temporary ectopic implantation for salvage of amputated digits. Br J Plast Surg 1996;47:174-77; Yousif NJ, Dzwierzynski WW, Anderson RC, et al. Complications and salvage of an ectopically replanted thumb. Plast Reconstr Surg 1996;97:637-40; Wang J-N, Tong Z-H, Zhang T-H, et al. Salvage of amputated upper extremities with temporary ectopic implantation followed by replantation at a second stage. J Reconstr Microsurg 2006;22:15-20]. Temporary ectopic implantation is usually considered due to poor conditions for replantation at the anatomic site. We report a case of near-total scalp avulsion treated by temporary implantation to the lower abdomen with secondary replantation.

Anti-atherosclerotic effect of microbial hyaluronate lyase from group B streptococci.

The effect of the microbial hyaluronic acid splitting enzyme hyaluronate lyase produced by Streptococcus agalactiae was investigated in vitro in human atherosclerotic plaque specimens and in vivo on Watanabe heritable hyperlipidaemic rabbits (WHHL) as an animal model for familiar hypercholesteraemia. The in vitro presence of the enzyme caused a partial destruction of the atherosclerotic plaque surfaces as well as releasing of glucuronic acid and solid calcium-containing materials from pieces of atherosclerotic plaques in human arteries. Accordingly hyaluronic acid seems to be the main component for anchoring of calcium deposits on the plaque surfaces. Repeated intravenous injections of hyaluronate lyase in WHHL rabbits resulted in a tendency of decreased formation of atherosclerotic plaques. The observed effects are discussed to be primary the result of the splitting of hyaluronic acid in the vessels.

Human Cdc45 is a proliferation-associated antigen.

Cell division cycle protein 45 (Cdc45) plays a critical role in DNA replication to ensure that chromosomal DNA is replicated only once per cell cycle. We analysed the expression of human Cdc45 in proliferating and nonproliferating cells. Our findings show that Cdc45 protein is absent from long-term quiescent, terminally differentiated and senescent human cells, although it is present throughout the cell cycle of proliferating cells. Moreover, Cdc45 is much less abundant than the minichromosome maintenance (Mcm) proteins in human cells, supporting the concept that origin binding of Cdc45 is rate limiting for replication initiation. We also show that the Cdc45 protein level is consistently higher in human cancer-derived cells compared with primary human cells. Consequently, tumour tissue is preferentially stained using Cdc45-specific antibodies. Thus, Cdc45 expression is tightly associated with proliferating cell populations and Cdc45 seems to be a promising candidate for a novel proliferation marker in cancer cell biology.

Transcallosal inhibition across the menstrual cycle: a TMS study.

OBJECTIVE: To determine if there are steroid-dependent changes in transcallosal transfer during the menstrual cycle in normal women. METHODS: We tested 13 normally cycling women during the menstrual, follicular and midluteal phases. Blood levels of estradiol (E) and progesterone (P) were determined by radioimmunoassay. Ipsilateral tonic voluntary muscle activity suppression, called ipsilateral silent period (iSP), was evoked by applying transcranial magnetic stimulation (TMS) over the left motor cortex and by measuring the EMG of the ipsilateral first dorsal interosseus (FDI) muscle. Both iSP-duration and transcallosal conduction times were measured and related to cycle phase and steroid levels. RESULTS: Duration of iSPs varied over the cycle with largest differences between follicular and midluteal phases. During the midluteal phase high levels of P were significantly related to short iSPs. This relation also applied to E levels and iSPs during the follicular phase. CONCLUSIONS: Our study shows for the first time that the transcallosal transfer is modulated by E and P and changes over the menstrual cycle. SIGNIFICANCE: It is suggested that gonadal steroid hormones affect the interhemispheric interaction and change the functional cerebral organization sex dependently via its neuromodulatory properties on GABAergic and glutamatergic neurons.

Potential role of the EPEC translocated intimin receptor (Tir) in host apoptotic events.

Apoptosis, or programmed cell death, is a well-ordered process that allows damaged or diseased cells to be removed from an organism without severe inflammatory reactions. Multiple factors, including microbial infection, can induce programmed death and trigger reactions in both host and microbial cellular pathways. Whereas an ultimate outcome is host cell death, these apoptotic triggering mechanisms may also facilitate microbial spread and prolong infection. To gain a better understanding of the complex events of host cell response to microbial infection, we investigated the molecular role of the microorganism Enteropathogenic Escherichia coli (EPEC) in programmed cell death. We report that wild type strain of EPEC, E2348/69, induced apoptosis in cultured PtK2 and Caco-2 cells, and in contrast, infections by the intracellularly localized Listeria monocytogenes did not. Fractionation and concentration of EPEC-secreted proteins demonstrated that soluble protein factors expressed by the bacteria were capable of inducing the apoptotic events in the absence of organism attachment, suggesting adherence is not required to induce host cell death. Among the known EPEC proteins secreted via the Type III secretion (TTS) system, we identified the translocated intimin receptor (Tir) in the apoptosis-inducing protein sample. In addition, host cell ectopic expression of an EPEC GFP-Tir showed mitochondrial localization of the protein and produced apoptotic effects in transfected cells. Taken together, these results suggest a potential EPEC Tir-mediated role in the apoptotic signaling cascade of infected host cells.

Fishing out proteins that bind to titin.

Another giant protein has been detected in cross-striated muscle cells. Given the name obscurin, it was discovered in a yeast two-hybrid screen in which the bait was a small region of titin that is localized near the Z-band. Obscurin is about 720 kD, similar in molecular weight to nebulin, but present at about one tenth the level (Young et al., 2001). Like titin, obscurin contains multiple immunoglobulin-like domains linked in tandem, but in contrast to titin it contains just two fibronectin-like domains. It also contains sequences that suggest obscurin may have roles in signal transduction. During embryonic development, its localization changes from the Z-band to the M-band. With these intriguing properties, obscurin may not remain obscure for long.

Elevated activity and expression of Src-family kinases in human breast carcinoma tissue versus matched non-tumor tissue.

Src-family kinase expression was measured in 52 human mammary tumor (T) specimens compared with non-tumor (NT) tissue from the same patient by enzymatic assays employing a Src-kinase family-specific peptide substrate and by immunoblotting with an antibody recognizing the Src-family kinases Src, Fyn, and Yes. In the T specimens, the mean enzymatic activity was moderately elevated (T: 160 fmol ATP min-1 mg-1; NT: 115 fmol ATP min-1 mg-1) with 25 tumor samples having higher activity than the corresponding NT tissue, 17 having lower activity, and no activity detectable in ten T/NT pairs. Immunoblotting revealed clearly elevated expression in 25 tumor tissues and no differences or expression below the detection limit in the remaining T/NT pairs. The data are in agreement with a possible role of Src-family kinases for the biology of mammary carcinoma.

Expression of green or red fluorescent protein (GFP or DsRed) linked proteins in nonmuscle and muscle cells.

The introduction of the green fluorescent protein (GFP) plasmids that allow proteins and peptides to be expressed with a fluorescent tag has had a major impact on the field of cell biology. It has enabled the dynamics of a wide variety of proteins to be analyzed that could not otherwise be detected in live cells. Transient transfections of muscle and nonmuscle cells with plasmids encoding various cytoskeletal proteins ligated to green fluorescent protein or Ds red protein allow changes in the cytoskeletal network to be studied in the same cell for time periods up to several days. With this approach, proteins that could not be purified and directly labeled with fluorescent dyes and microinjected into cells can now be expressed and visualized in a wide variety of cells. Procedures are presented for transfection of the nonmuscle cell, PtK2, and primary cultures of embryonic chick myocytes, and for studying the live transfected cells.

Gait analysis in rats with peripheral nerve injury.

Rats are commonly used to study peripheral nerve repair and grafting. The traditional footprint method to assess functional recovery is messy, indirect, and not useful when contractures develop in the animal model. The aim of the present study was to establish an accurate, reproducible, but simple, method to assess dynamic limb function. The basic quantitative aspects of a normal gait were characterized from 59 recorded walks in 23 rats. The video was digitized and analyzed frame by frame on a personal computer. Seven parameters of the gait were assessed: (1) walking speed; (2) stance phase, swing phase and right to left stance/swing ratio; (3) step length and step length ratio; (4) ankle angles at terminal stance and midswing; (5) tail height; (6) midline deviation; and (7) tail deviation. These gait parameters were then applied to groups of animals with sciatic (group S), tibial (group T), and peroneal (group P) nerve injuries. A discriminant analysis was performed to analyze each parameter and to compute a functional score. We found that the video gait analysis was superior to the footprint method and believe it will be very useful in future studies on peripheral nerve injury.

Salvage of ischemic digits using a lateral arm fascial flap.

Four patients underwent microvascular transfer of a lateral arm fascial flap to salvage severely ischemic digits by means of induction of neovascularization. The cause of the digital ischemia was direct trauma (crush injury) in one patient and chronic embolic phenomena (proximal arterial occlusion) in three patients. None of the patients had responded to traditional therapy, including treatment with one or more of the following: anticoagulation, lytic therapy, oral vasodilators, digital sympathectomy, and vein bypass grafting. Each patient underwent noninvasive (Doppler ultrasound, digital pressures, digital temperatures, vascular refill) and invasive (angiogram) vascular assessment preoperatively. After microvascular transfer of the lateral arm fascial flap, all patients reported symptomatic relief, and objective improvements were documented by both noninvasive and invasive assessment criteria. One patient developed a seroma at the donor site; another experienced a late complication of thrombosis of the flap after his wound dehisced. A 6-month follow-up evaluation demonstrated neovascular collateralization and stable improvement without regression in the remaining patients. The authors present their clinical experience and propose a treatment algorithm for patients with chronic digital ischemia.

Psychological adjustment in children after traumatic disfiguring injuries: a 12-month follow-up.

The psychological adjustment of 57 children (age range, 3 to 12 years) who sustained mutilating traumatic injuries to the face or upper or lower extremities was assessed over a 12-month interval. The injuries had occurred as a result of boating, lawn mower, or home accidents or dog bites. Within 5 days of the traumatic event, 98 percent of the children were symptomatic for posttraumatic stress disorder, depression, or anxiety. One month after the injury, 82 percent were symptomatic. Symptom frequency had declined by the time of the 3-month and 6-month evaluations, but 44 percent of the children continued to report symptoms at 12-month follow-up visits, and 21 percent met the diagnostic criteria for posttraumatic stress disorder. Typical symptoms included flashbacks, fear of re-injury, mood disorders, body-image changes secondary to disfigurement, sleep disturbances, and anxiety. These findings support the importance of psychological evaluation and treatment of children who suffer mutilating injuries that require the attention of plastic surgeons.

Interaction of the enteropathogenic Escherichia coli protein, translocated intimin receptor (Tir), with focal adhesion proteins.

When enteropathogenic Escherichia coli (EPEC) attach and infect host cells, they induce a cytoskeletal rearrangement and the formation of cytoplasmic columns of actin filaments called pedestals. The attached EPEC and pedestals move over the surface of the host cell in an actin-dependent reaction [Sanger et al., 1996: Cell Motil Cytoskeleton 34:279-287]. The discovery that EPEC inserts the protein, translocated intimin receptor (Tir), into the membrane of host cells, where it binds the EPEC outer membrane protein, intimin [Kenny et al., 1997: Cell 91:511-520], suggests Tir serves two functions: tethering the bacteria to the host cell and providing a direct connection to the host's cytoskeleton. The sequence of Tir predicts a protein of 56.8 kD with three domains separated by two predicted trans-membrane spanning regions. A GST-fusion protein of the N-terminal 233 amino acids of Tir (Tir1) binds to alpha-actinin, talin, and vinculin from cell extracts. GST-Tir1 also coprecipitates purified forms of alpha-actinin, talin, and vinculin while GST alone does not bind these three focal adhesion proteins. Biotinylated probes of these three proteins also bound Tir1 cleaved from GST. Similar associations of alpha-actinin, talin, and vinculin were also detected with the C-terminus of Tir, i.e., Tir3, the last 217 amino acids. Antibody staining of EPEC-infected cultured cells reveals the presence of focal adhesion proteins beneath the attached bacteria. Our experiments support a model in which the cytoplasmic domains of Tir recruit a number of focal adhesion proteins that can bind actin filaments to form pedestals. Since pedestals also contain villin, tropomyosin and myosin II [Sanger et al., 1996: Cell Motil. Cytoskeleton 34:279-287], the pedestals appear to be a novel structure sharing properties of both focal adhesions and microvilli.

Assembly of myofibrils in cardiac muscle cells.

How do myofibrils assemble in cardiac muscle cells? When does titin first assemble into myofibrils? What is the role of titin in the formation of myofibrils in cardiac muscle cells? This chapter reviews when titin is first detected in cultured cardiomyocytes that have been freshly isolated from embryonic avian hearts. Our results support a model for myofibrillogenesis that involves three stages of assembly: premyofibrils, nascent myofibrils and mature myofibrils. Titin and muscle thick filaments were first detected associated with the nascent myofibrils. The Z-band targeting site for titin is localized in the N-terminus of titin. This region of titin binds alpha-actinin and less avidly vinculin. Thus the N-terminus of titin via its binding to alpha-actinin, and vinculin could also help mediate the costameric attachment of the Z-bands of mature myofibrils to the nearest cell surfaces.