Bleeding Mass in Remnant Stomach, Unveiling Lynch Syndrome 18 Years After Bariatric Roux-En-Y Gastric Bypass Surgery.

There is sparse literature on the development of malignancy in remnant gastric stomach after bariatric Roux-en-Y gastric bypass surgery. We report a case of overt upper gastrointestinal bleeding from malignant adenocarcinoma in the remnant stomach presenting several years after bariatric Roux-En-Y gastric bypass surgery. The mass in the remnant stomach was surgically resected, and the patient was subsequently diagnosed with Lynch syndrome on genetic analysis.

Structure-Function Correlations in the Mechanism of Action of Key Antiperspirant Agents Containing Al(III) and ZAG Salts.

Aluminum hydrolysis chemistry is an important part of modern society because of the dominance of Al(III) as a highly effective antiperspirant active. However, the century-old chemistry centered on aluminum chloride (ACL) is not comprehensive enough to address all of the in vivo events associated with current commercial antiperspirants and their mechanism of action. The present study aims to address the knowledge gap among extensively studied benchmark ACL, its modified version aluminum chlorohydrate (ACH), and a more complex but less explored group of aluminum zirconium chlorohydrate glycine complexes (ZAG salts) toward understanding the mechanism of action under consumer-relevant conditions. ACH, which is the Al source used in the manufacture of ZAG salts, provides a bridge between ACL and ZAG chemistry. High viscosity and gel formation driven by pH and a specific Al(III) salt upon hydrolysis are considered the criteria for building an in vivo occlusive mass to retard or stop the flow of sweat to the skin surface, thus providing an antiperspirant effect. Rheological studies indicated that ACL and aluminum zirconium tetrachlorohydrex glycine (TETRA) were the most efficacious salt actives. Spectroscopic studies, diffraction studies, and elemental analysis suggested that small metal oxide and hydroxide species with coparticipating glycine as well as various polynuclear and oligomeric species are the key to gel formation. At a given pH, the key ingredients (NaCl, urea, bovine serum albumin, and lactic acid) in artificial sweat were found to have little influence on Al(III) salt hydrolysis. The effects of the sweat components were mostly limited to local complex formation and kinetic modification. The in vitro comparative experiments with various Al(III) and ZAG salt systems offer unprecedented insights into the chemistry of different salt types, thus paving the way for engineering more efficacious antiperspirant systems.

Appendectomy in the gynecological setting: intraoperative findings and corresponding histopathology.

BACKGROUND/AIMS: To evaluate the intraoperative findings and corresponding histopathology associated with appendectomies performed during benign gynecological surgery. METHODS: Retrospective case series. RESULTS: Twenty-two appendectomies were performed from 2002 through 2008 at Hutzel Women's Hospital due to intraoperative findings of inflammation or erythema (n = 8), periappendiceal adhesions (n = 5), injury to the appendix or mesoappendix (n = 2), fecalith (n = 2), dilation of the appendix (n = 1), adnexal mass involving the appendix (n = 1), and suspected lipoma (n = 1). Final pathology was consistent with significant findings such as acute inflammation, periappendicitis, and adhesions or endometriosis involving the appendix in 68.2% of cases. CONCLUSION: In the benign gynecological setting, appendectomies were primarily performed due to inflammation or erythema. In the majority of cases, significant appendiceal pathology was confirmed.

Combined endoscopic and laparoscopic approach to a gastroesophageal tumor.

BACKGROUND AND OBJECTIVES: Smooth muscle tumors of the stomach, especially when benign, are a common clinical entity and can represent a therapeutic challenge. Classically the removal of such a tumor requires open laparotomy. We sought to perform this surgery utilizing minimally invasive technology. METHODS: We describe a minimally invasive technique combining laparoscopy with endoscopy to remove a sub-mucosal leiomyoma at the gastroesophageal junction. RESULTS: A 3.3-cm smooth muscle tumor of the gastroesophageal junction was removed completely and safely with the described procedure and thus saved the patient from requiring a laparotomy. CONCLUSION: Minimally invasive techniques can be used in combination to tackle difficult problems in general surgery leading to shorter hospital stays and improved patient satisfaction.

Signet-Ring Cell Colon Cancer in a Teenager: A Case Report.

The majority of colon cancers are diagnosed in the older population, though recent trends have demonstrated an increase in younger patients. Most colon cancers are considered adenocarcinoma. There are multiple histologic subtypes with varying prognoses. Mucinous types such as signet-ring cell carcinoma (SRCC) are more aggressive with poor outcomes. SRCC frequently presents with metastatic disease which contributes to its poor prognosis. It is most commonly diagnosed around age 40. SRCC of colonic origin is very rare and comprises only 1% of colorectal cancers. Rarer still is presentation in the teenaged patient, especially in the absence of any risk factors. We present a case of an 18-year-old male with colonic SRCC. The patient presented initially with vague abdominal discomfort and three weeks later was found to have a near-obstructing right-sided colon mass. He was taken to the operating room and found to have diffuse carcinomatosis. The patient underwent palliative loop ileostomy with plans for subsequent chemotherapy.

Susceptibility of Some Corylus avellana L. Cultivars to Xanthomonas arboricola pv. corylina.

Bacterial blight of hazelnut (Corylus avellana L.) is caused by Xanthomonas arboricola pv. corylina (Xac). In the past, bacterial blight has been a key disease impacting the Oregon hazelnut industry where 99% of the United States hazelnut crop is grown. The disease is re-emerging in young orchards, as acreage of newly released hazelnut cultivars rapidly increases. This increase in hazelnut acreage is accompanied by renewed interest in developing control strategies for bacterial blight. Information on susceptibility of hazelnut cultivars to Xac is limited, partially due to lack of verified methods to quantify hazelnut cultivar response to artificial inoculation. In this research, Xac inoculation protocols were adapted to two hazelnut growing environments to evaluate cultivar susceptibility: in vitro tissue culture under sterile and controlled conditions, and in vivo potted tree conditions. Five hazelnut cultivars were evaluated using the in vitro inoculation protocol and seven hazelnut cultivars were evaluated using the in vivo inoculation protocol. Under in vitro conditions, there were severe bacterial blight symptoms on each cultivar consistent with those seen in the field, but no significant differences in the susceptibility of the newly released cultivars were observed compared to known Xac-susceptible cultivar ("Barcelona"). Under in vivo conditions, the proportion of necrotic buds were significantly higher in "Jefferson" and "Dorris" compared to all of the other tested cultivars, including "Barcelona." The symptom progression seen in vivo mirrored the timing and symptom progression of bacterial blight reported from field observations. The in vitro conditions significantly reduced the amount of time required to measure the inoculation efficiency compared to the in vivo environment and allowed for greater replication. Further studies on the effects of Xac can use the results of these experiments to establish a dose-response model for bacterial blight, a wider range of germplasm can be tested under in vitro conditions, and management strategies that can be evaluated on large populations of new cultivars using the in vivo methods.

A Roadmap for Participatory Chestnut Breeding for Nut Production in the Eastern United States.

Chestnut cultivation for nut production is increasing in the eastern half of the United States. Chinese chestnuts (Castanea mollissima Blume), or Chinese hybrids with European (C. sativa Mill.) and Japanese chestnuts (C. crenata Sieb. & Zucc.), are cultivated due to their high kernel quality, climatic adaptation, and disease resistance. Several hundred thousand pounds of high-quality fresh nuts are taken to market every fall, and several hundred additional orchards are entering bearing years. Grower-led on-farm improvement has largely facilitated this growth. A lack of significant investments in chestnut breeding in the region, paired with issues of graft incompatibility, has led many growers to cultivate seedlings of cultivars rather than grafted cultivars. After decades of evaluation, selection, and sharing of plant materials, growers have reached a threshold of improvement where commercial seedling orchards can be reliably established by planting offspring from elite selected parents. Growers recognize that if cooperation persists and university expertise and resources are enlisted, improvement can continue and accelerate. To this end, the University of Missouri Center for Agroforestry (UMCA) and chestnut growers throughout the eastern United States are partnering to formalize a participatory breeding program - the Chestnut Improvement Network. This partnership entails the UMCA providing an organizational structure and leadership to coordinate on-farm improvement, implement strategic crossing schemes, and integrate genetic tools. Chestnut growers offer structural capacity by cultivating seedling production orchards that provide financial support for the grower but also house segregating populations with improved individuals, in situ repositories, and selection trials, creating great value for the industry.

Prophylactic laparoscopic gastrectomy for hereditary diffuse gastric cancer: a case series in a single family.

BACKGROUND: Hereditary diffuse gastric carcinomas (HDGCs) are particularly troubling because of autosomal dominant heritance, high penetrance, early age of onset, and a lack of effective treatment once symptomatic. HDGC is further complicated by difficulty of effective screening. Gastrectomy provides definitive treatment for CDH1 mutation-positive patients. Attempting to minimize the morbidity and mortality of this procedure via a laparoscopic approach is appropriate. METHODS: Six consanguineous patients, 21 to 51 years of age, were identified as carriers of the CDH1 gene mutation. All of the patients' gastric mucosa was normal by endoscopic appearance and biopsy. After appropriate multispecialty counseling, all patients elected to undergo a laparoscopic total gastrectomy. Demographics, genealogy, operative approach, outcomes, and pathology were reviewed. RESULTS: All gastrectomies were completed using a laparoscopic approach. Gross examination of resected stomachs was unremarkable. Histological examination demonstrated multiple foci of invasive signet ring adenocarcinoma in all patients. There were no anastomotic leaks, one small bowel obstruction requiring reoperation, and one esophageal stricture requiring dilation. CONCLUSIONS: This series demonstrates the utility and safety of the laparoscopic approach for prophylactic total gastrectomy for carriers of the CDH1 gene mutation. It serves to highlight that patients with CDH1 mutations may be more likely to undergo gastrectomy if they are offered the lower risk laparoscopic approach.

Identity and pathogenicity of some fungi associated with hazelnut (Corylus avellana L.) trunk cankers in Oregon.

Four fungi isolated from trunks and branches of European hazelnut (Corylus avellana L.) from commercial orchards in the Willamette Valley, Oregon were characterized and pathogenicity was tested on potted hazelnut trees. The acreage of hazelnuts in Oregon has expanded greatly in recent years in response to the availability of Eastern filbert blight resistant cultivars. Fungi were characterized using the BLASTn algorithm and the GenBank database with multiple partial gene sequence(s). If BLASTn and GenBank were not sufficient for species-level identification, then a multilocus sequence analysis (MLSA) was performed. The four pathogens were identified as Diplodia mutilla (Fr.) Mont., Dothiorella omnivora B.T. Linaldeddu, A. Deidda & B. Scanu, Valsa cf. eucalypti Cooke & Harkn., and Diaporthe eres Nitschke. All pathogens but D. omnivora have not been previously reported from European hazelnut in the literature. All four pathogens caused lesions on trunks bare root hazelnut trees cv. 'Jefferson' planted in pots in the greenhouse and fungi were re-isolated from inoculated trees. D. mutilla appeared particularly aggressive in repeated inoculation experiments.

Translating chemometric analysis into physiological insights from in vivo confocal Raman spectroscopy of the human stratum corneum.

The superficial layer of the skin, the stratum corneum (SC), consists of corneocytes surrounded by lipid regions and acts as a protective barrier for the body against water loss, toxic agents and microorganisms. As most substances permeate the stratum corneum through the lipid regions, lipid organization is considered crucial for the skin barrier function. Here, we investigate the potential of in vivo confocal Raman spectroscopy to describe the composition and organization of the SC. Confocal Raman spectroscopy is finding increasing use in the characterization of skin in biomedical, pharmaceutical and cosmetic applications. In this work, we analyze the spectra using chemometric methods and obtain principal components that correspond to the primary skin constituents: protein (keratin), natural moisturizing factor (NMF), water and lipid contributions in both ordered (orthorhombic) and disordered structural organization. By identifying these important components of the SC, these results highlight the utility of this in vivo, non-invasive, and depth resolved tool at the forefront of skin research.

Prophylactic laparoscopic-assisted total gastrectomy for hereditary diffuse gastric cancer.

BACKGROUND: Ten percent of gastric cancer (GC) cases are familial, with one third resulting from a mutation in the tumor suppressor gene CDH1. Loss of this important structure can result in hereditary diffuse gastric cancer (HDGC), which carries a high mortality if early diagnosis is not made. Despite its clear genetic origin, optimal management of HDGC family members is controversial, as the utility and efficacy of current cancer screening programs for mutation carriers are unproven. METHODS: A 53-year-old Caucasian woman was initially seen for genetic screening because multiple family members had mutations of the CDH1 gene. Her pedigree analysis demonstrated 4 generations of gastric cancer, and 2 of the generations carried the CDH1 germline mutation, consistent with HDGC. At endoscopy, the patient's gastric mucosa was normal and random biopsies were also normal. The patient underwent a laparoscopic total gastrectomy. RESULTS: The gross examination of her stomach appeared normal. On histologic examination, however, the stomach was found to have diffuse (signet ring cell) adenocarcinoma in-situ with 11 microscopic foci of invasive adenocarcinoma limited to the lamina propria. CONCLUSION: Our case is the first reported prophylactic total gastrectomy utilizing a laparoscopic approach, and it highlights the importance of taking a thorough family history and obtaining a pedigree analysis. Endoscopic screening in HDGC cannot rule out diffuse GC, because the stomach and biopsies can be normal despite the presence of adenocarcinoma. Therefore, our case supports the recommendation for prophylactic gastrectomy in HDGC.

Laparoscopic removal of a retained intra-abdominal ribbon malleable retractor after 14 years.

We report a case of the laparoscopic removal of a 33 x 5 cm ribbon malleable retractor retained intra-abdominally for 14 years. Plain films revealed a radiopaque object in the midline abdomen consistent with a metallic device. This was a ribbon malleable retractor which was subsequently removed laparoscopically without complication. Laparoscopic surgery should be considered in the removal of foreign bodies from the abdominal cavity.

Solid-pseudopapillary tumors of the pancreas: case report and literature review.

Solid pseudopapillary tumors (SPT) of the pancreas are rare neoplasms of low malignant potential that mostly affect young women. These tumors are of unclear pathogenesis, are slow growing, and can become considerably large before causing symptoms. Complete resection is curative in most cases. This is the case of a 39-year-old African-American woman undergoing evaluation for Roux-en-Y gastric bypass, who was found to have a pancreatic mass. Image-guided biopsy revealed SPT. The patient underwent complete excision of the tumor and had an open Roux-en-Y gastric bypass performed concurrently. The patient had an uneventful postoperative course. A review of the literature is presented.

Killing tumor cells: the effect of photodynamic therapy using mono-L-aspartyl chlorine and NS-398.

BACKGROUND: Photodynamic therapy (PDT) is a useful treatment for malignant tumors. PDT involves the administration of a photosensitive drug that is selected by neoplastic tissues and their vasculature. One such photosensitizer is mono-l-aspartyl chlorine e6 (NPe6). Recent evidence suggests that the presence of the cyclooxygenase-2 (COX-2) inhibitor NS-398 may potentiate the effect of photosensitizing agents. This study was designed to determine if the addition of NS-398 to NPe6-induced PDT in single or fractionated dosing would result in greater tumor kill. METHODS: Colon-38 tumor was subcutaneously implanted into both flanks of mice and allowed to grow to 0.5 to 1.0 cm. Mice were randomly allocated to 5 groups: (1) single dose of NPe6; (2) fractionated dose of NPe6; (3) NS-398 only; (4) single dose of NPe6 + NS-398; and (5) fractionated dose of NPe6 + NS-398. The left flank was shielded from exposure to irradiation. Tumor size was measured before initiation of PDT and at the time of sacrifice. RESULTS: The initial tumor weights of both flanks were not significantly different between all groups. Tumor weights at the time of death after PDT using NPe6 were significantly less than their paired tumors in the untreated flanks (P <0.0001). Tumor weights in the treated flanks were significantly less in the group receiving the fractionated dosing of NPe6 as compared to the single dose of NPe6 (P = 0.0037). NS-398 plus the single dose of NPe6 significantly decreased tumor weight in the PDT-treated flank (P = 0.035) at a level equivalent to that observed with fractionated dosing of the photosensitizer in the absence of NS-398. NS-398 did not significantly further decrease tumor weight in the group that received the fractionated dose of NPe6. CONCLUSIONS: Fractionated dosing of NPe6 demonstrated the best tumor kill. However, NS-398 did not potentiate the effect of PDT using fractionated dosing of NPe6. While PDT using the single NPe6 dose significantly decreased tumor weight, the addition of NS-398 potentiated the killing effect.

Effects of photodynamic therapy using a fractionated dosing of mono-L-aspartyl chlorin e6 in a murine tumor.

One of the 'second generation' photosensitizing agents is N-acetyl chlorin e6 (NPe6). This product has a strong absorbance band at 665 nm, permitting treatment at a greater depth of tumor than earlier agents based on porphyrin structures. We examined the effects of fractionated drug administration on photodynamic efficacy. Prior studies had shown that it is the level of NPe6 in the circulation that predicts for photodynamic efficacy, indicating vascular shut-down to be the predominant mode of tumor control. Although pharmacokinetic studies revealed that >99% of NPe6 was lost from the circulation, it appears that a fractionated dosage protocol can promote photodamage to neoplastic tissue in vivo. This study also indicated the potential utility of an implantable micro array for tumor irradiation.

Photodynamic therapy for carcinoma in situ of the anus.

HYPOTHESIS: Photodynamic therapy (PDT) for carcinoma in situ of the anus is an alternative to surgical excision in patients who are seropositive for human immunodeficiency virus (HIV). DESIGN: Before-after trial. Settings Tertiary referral center. PATIENTS: Twelve HIV-seropositive patients who were actively being treated for AIDS with high-grade dysplasia on anal Papanicolaou test results had site-directed biopsies of acetowhitening foci immediately after application of dilute acetic acid. Biopsy results showed that 5 patients had anal carcinoma in situ. These patients were given the photosensitizer delta-aminolevulinic acid orally. Four to 4.25 hours later, the entire anal circumference was treated with PDT. All 5 patients, after being treated with PDT, had repeated Papanicolaou tests at monthly intervals. If acetowhitening occurred at the fifth month, site-directed biopsy was done. MAIN OUTCOME MEASURES: Anal cytologic examination by Papanicolaou test and site-directed biopsy if acetowhitening was found at 5 months in order to determine effectiveness of PDT in downstaging cytologic findings. RESULTS: All patients had a consistent downgrading of cytologic findings during the 5 months of follow-up. Papanicolaou test results showed 2 patients had no dysplasia, 2 had mild dysplasia, and 1 had moderate dysplasia. Moderate dysplasia was confirmed by site-directed biopsy results. No complications of PDT occurred, but all 5 patients developed various abnormalities in liver function test results that returned to baseline values within 2 weeks; this also has been noted in patients ingesting delta-aminolevulinic acid who are presumably HIV seronegative. CONCLUSION: In a group of patients who are at high risk for recurrence irrespective of initial treatment, PDT can be used as a successful alternative to surgical excision for anal carcinoma in situ.

Spontaneous cystic duct perforation associated with acalculous cholecystitis.

Spontaneous perforation of the extrahepatic biliary tree is rare in adults. Although perforation of the hepatic, common hepatic, common bile, and cystic ducts has been reported, review of the English literature reveals only four cases of cystic duct perforation, each attributed to calculi. We herein report the first known case of spontaneous perforation of the cystic duct in the absence of biliary calculi.

Organ failure in the obese adipocytes prime polymorphonuclear cell inflammation under stress conditions.

BACKGROUND: Obesity is associated with a higher risk of remote organ failure after shock and trauma. The mechanism(s) is poorly understood. Polymorphonuclear cell (PMN) inflammatory responses are important in the pathogenesis of organ injury following shock. Morbid obesity is a low-grade inflammatory state associated with proinflammatory mediator production from adipose tissue. We hypothesized that adipose tissue may modulate PMN inflammatory potential and is dependent on the magnitude of the injury-related stress response. This was studied in an in vitro model. METHODS: Adipose-derived stem cells (ADSCs) conditioned to behave as mature adipocytes were incubated with physiologic and stress concentrations of adrenaline for 12 hours, and cell culture supernatants were obtained. PMNs from normal human volunteers were cocultured with the ADSC supernatants (priming) followed by addition of 1-µM fMLP (activation). PMNs alone served as control. PMN activation was indexed by superoxide anion (O2) production, elastase release (%) and CD11b expression (mean fluorescent intensity). RESULTS: Physiologic and stress levels of adrenaline resulted in significantly increased PMN activation in the presence or absence of adipocytes. However, the largest increase was noted in PMNs exposed to ADSC culture supernatants that had been cocultured with stress levels of adrenaline for 12 hours, twofold increase in CD11b expression and fourfold increase in superoxide anion and percent elastase release. CONCLUSION: Adipocyte-derived mediators prime PMNs in vitro. There was a graded PMN response to adrenaline concentration with or without adipocytes in these experiments. The most profound increase in PMN inflammatory potential was noted with the adipocyte supernatant + stress adrenaline group. The clinical impact of obesity on remote organ injury is likely dependent on patient body mass index and the injury-related sympathetic responses. These data suggest a potential role for ß blockade in this patient population.