The use of double lasso, fully covered self-expandable metal stents with new "anchoring flap" system in the treatment of benign biliary diseases.

BACKGROUND: Many benign biliary diseases (BBD) can be treated with fully covered, self-expandable metal stents (FCSEMS) but stent migration occurs in up to 35.7 %. The aim of this study was to prospectively assess the rate of, safety and effectiveness and stent migration of a new biliary FCSEMS with an anti-migration flap (FCSEMS-AF) in patients with BBD. PATIENTS AND METHODS: This was a prospective study from four Italian referral endoscopy centers of 32 consecutive patients (10 females and 22 males; mean age: 60.1 ± 14.8 years; range: 32-84 years) with BBD who were offered endoscopic placement of a FCSEMS-AF as first-line therapy. RESULTS: Were 24 strictures and 8 leaks. Stent placement was technically successful in 32/32 patients (100 %). Immediate clinical improvement was seen in all 32 patients (100 %). One late stent migration occurred (3.3 %). FCSEMS-AF were removed from 30 of the 32 patients (93.7 %) at a mean (± SD) of 124.4 ± 84.2 days (range: 10-386 days) after placement. All patients remained clinically and biochemically well at 1- and 3-month follow-up. One patient (3.3 %) with a post-laparoscopic cholecystectomy stricture developed distal stent migration at 125 days. CONCLUSION: This new FCSEMS with anti-migration flap seems to be a safe and effective first-line treatment option for patients with BBD.

The contribution of L3T4+ T cells to lymphoproliferation and autoantibody production in MRL-lpr/lpr mice.

The current study examines the role of the L3T4 T cell subset in the development of lupus-like autoimmunity and lymphoproliferation in lpr-bearing mice. Chronic treatment of MRL-lpr/lpr mice with anti-L3T4 antibody beginning at 4 wk old was found to markedly decrease the production of IgG anti-DNA and antihistone antibodies, while having no effect on IgM autoantibodies. A dramatic reduction in splenomegaly and lymphadenopathy was also observed coincident with a decrease in the percentage and total number of Thy-1+, B220+ cells. Together, the data suggest an important role for L3T4+ T cells in the pathogenesis of disease in lpr mice and provide further evidence that a requirement for the L3T4 subset may be a common feature of murine autoimmunity.

Aberrant production of leukotriene C4 by macrophages from autoimmune-prone mice.

Eicosanoids have been implicated in the pathogenesis of autoimmune diseases. In this study, peritoneal macrophages from autoimmune-prone mice were examined for their capacity to produce proinflammatory 5-lipoxygenase metabolites. The results indicate that enhanced production of leukotriene C4 is a common feature of murine autoimmunity and suggest further that aberrations in 5-lipoxygenase activity may play a role in the development of lupus.

Incorporation, distribution, and turnover of arachidonic acid within membrane phospholipids of B220+ T cells from autoimmune-prone MRL-lpr/lpr mice.

The metabolism of AA-containing phosphoglycerides within T cell membranes leads to the generation of second messengers that appear to play a crucial role in transmembrane signal transduction. To test the hypothesis that aberrations in the movement of arachidonoyl-phospholipids are associated with and may potentially contribute to abnormal T cell function, the incorporation, distribution, and turnover of AA within the membrane glycerolipids of cells that are known to exhibit immunoregulatory disturbances was examined. Thy-1+, Ly-1+, L3T4-, Lyt-2-, B220+ T cells from autoimmune MRL-lpr/lpr mice were used as the cellular model. In contrast to control lymph node T cells, which preferentially incorporate labeled AA into phosphatidylcholine (PC), B220+ T cells displayed a predilection for distributing [3H]arachidonate into phosphatidylinositol (PI). The arachidonoyl-phospholipid pools were normal in B220+ T cells. The constitutive turnover of [3H]arachidonoyl-PI was significantly enhanced and that of [3H]arachidonate-PC substantially reduced in B220+ T cell compared with control cells. Using membrane homogenates B220+ T cells demonstrated a functional increase in the levels of lyso-PI. Intact B220+ T cells prelabeled with [3H]myoinositol and cultured in the absence of stimulation with exogenous antigens or mitogens, exhibited increased production of lyso-PI. The data indicate that the preferential formation of [3H]arachidonoyl-PI in B220+ T cells is the result of greatly increased, constitutive PI turnover that appears to be due to a membrane phospholipase A2 activity. It remains possible that disturbances in the movement of arachidonate within phospholipids of B220+ T cells play a role in the expression of aberrant immunological activity.

Gem: an induced, immediate early protein belonging to the Ras family.

A gene encoding a 35-kilodalton guanosine triphosphate (GTP)-binding protein, Gem, was cloned from mitogen-induced human peripheral blood T cells. Gem and Rad, the product of a gene overexpressed in skeletal muscle in individuals with Type II diabetes, constitute a new family of Ras-related GTP-binding proteins. The distinct structural features of this family include the G3 GTP-binding motif, extensive amino- and carboxyl-terminal extensions beyond the Ras-related domain, and a motif that determines membrane association. Gem was transiently expressed in human peripheral blood T cells in response to mitogenic stimulation; the protein was phosphorylated on tyrosine residues and localized to the cytosolic face of the plasma membrane. Deregulated Gem expression prevented proliferation of normal and transformed 3T3 cells. These results suggest that Gem is a regulatory protein, possibly participating in receptor-mediated signal transduction at the plasma membrane.

[Polycystic ovary syndrome and obesity: non pharmacological approaches]. / Sindrome dell'ovaio policistico e obesità approcci non farmacologici.

In patients affected of polycystic ovary syndrome (PCOS), obesity has an high percent of incidence and represents an important factor increasing its clinic evolution, both in metabolic than in reproductive terms. For these patients non pharmacologic treatments aimed at the reduction of body weight, such as diets and physical exercise, represent the first line therapeutic approach. The aim of this review is to analyze the changes in life style and to highlight their efficacy in reducing the negative effects of PCOS on metabolism and reproductivity. Specifically different types of diet have been compared, in health or PCOS women, such as low glycemic index diets, moderate carbohydrate, high protein and low fat diets, very low carbohydrate and high fat diets and, finally, moderate carbohydrate and high monounsaturated fat diets. In the global view of the approach to the disease, different regimens of physical activity and the usefulness of a behavior therapy were also evaluated. Results obtained in health women suggest that diets higher in proteins and lower in carbohydrates are to be preferred to the conventional diet lower in fats and higher in carbohydrates. Anyway other studies are necessary to justify a similar assertion in women with PCOS. At the same way, the optimum regimen of physical exercise for PCOS women is still to be demonstrated.

A Novel Mycoplasma sp. Associated with Phallus Disease in Goose Breeders: Pathological and Bacteriological Findings.

In April 2014, poor fertility in a major commercial goose breeder operation in California triggered the submission of six live affected Toulouse ganders ( Anser anser ) to the California Animal Health and Food Safety Laboratory, Turlock branch (University of California-Davis). Toulouse were principally affected among all breeds, and their egg fertility dropped from 65.7% to less than 33.9% in the first 40 days of the 2014 breeding season. The flock consisted of 410 adult birds, 90 males and 320 females, between 2 and 5 yr of age. Inspection of the flock revealed that 44.4% of the Toulouse ganders had severe phallic deformities that prevented them from mating. At postmortem examination, severe yellowish fibrocaseous exudate disrupted the architecture of the phallus and occasionally produced fistulating tracts through the wall of the organ. Microscopically, multifocal lymphoid nodules were noted in the mucosa and submucosa of the phallus and were associated with extensive granulomatous reaction, intralesional bacteria, and spermatozoa. Mycoplasma spp. were isolated from the phallus of affected and nonaffected birds, and PCR protocols targeting the 16S-23S ribosomal RNA intergenic spacer regions and the RNA polymerase beta subunit gene were performed to identify the isolates. Three distinct species were identified on sequencing and analysis using the National Center for Biotechnology Information basic local alignment search tool: Mycoplasma cloacale , Mycoplasma anseris , and an unknown novel Mycoplasma sp. Additionally, Pasteurella multocida , in combination with other bacteria, was also isolated from the phallic lesions and identified as serotype 3 with a DNA profile of 1511 (National Veterinary Service Laboratory). This is the first report of these Mycoplasma spp. and other bacteria associated with reproductive disease in ganders in the United States.

Long chain fatty acid utilization of T-cells from autoimmune MRL-lpr/lpr mice.

To test the hypothesis that T-cells which exhibit abnormal immunological behavior manifest derangements in the de novo synthesis of phospholipids, the utilization of [3H]palmitic acid in B220+ T-cells from autoimmune MRL-lpr/lpr mice was investigated. The rate of incorporation of [3H]palmitic acid into membrane phospholipids was markedly increased in intact B220+ T-cells compared to that in T-cells from immunologically normal mice. The activities of two key enzymes involved in the de novo synthesis of palmitoyl-phospholipids, acyl-coenzyme (CoA) ligase and acyl-CoA; sn-glycerol-3-phosphate acyl transferase, were significantly higher in homogenates from B220+ T-cell membranes compared with those in controls. Despite these findings, the molar concentration of individual palmitoyl glycerolipids was equivalent in the membranes of B220+ T-cells and control lymph node T-cells. The results indicate that T-cells from lupus mice exhibit complex defects in the biosynthesis and turnover of membrane phospholipids and suggest the possibility that these aberrations contribute to T-cell dysfunction in autoimmune diseases.

Role of T cells in sex differences in syngeneic bone marrow transfers.

Transferred marrow cells will proliferate in normal mice not exposed to irradiation or any other type of stem cell depletion when five consecutive transfers of 40 million cells are given. Approximately 25% of the mitotic cells are of male donor origin observed cytogenetically in all of the female recipient spleens and marrow analyzed from two weeks to one and one-half years after transfusions. Male donor stem cells are accepted and form a stable component of the self-renewing stem cell pool. In contrast, only 5% female cells are found in male recipients. This sex difference in engraftment is not hormonal since castration of recipients does not alter the percentage of donor cells. Rigorous T depletion of female donor bone marrow, however, increases the percentage of donor engraftment to the level observed when male marrow, either whole or T depleted, is transferred to female recipients. The success of T-depleted female stem cells to seed male recipients is observed in both C57BL/6, a responder strain in which females readily respond to the H-Y antigen as manifest by skin graft rejection, and CBA/J, a strain in which females do not readily respond to H-Y. In addition, recipient nude BALB/c males, which lack a thymus, fail to accept whole bone marrow from BALB/c females. However, male bone marrow cells seed BALB/c nude females. These studies demonstrate that the poor engraftment of female cells in transfused male recipients is abrogated by the removal of T cells from the donor female marrow.

Dipyridamole stress echocardiography vs dipyridamole sestamibi scintigraphy for diagnosing coronary artery disease in left bundle-branch block.

STUDY OBJECTIVES: To evaluate dipyridamole stress echocardiography (DSE) for predicting coronary artery diseases (CADs) in patients with complete left bundle-branch block (LBBB). DESIGN: Comparison of DSE and dipyridamole sestamibi myocardial perfusion scintigraphy (sestamibi). SETTING: Tertiary-care cardiac referral center. PATIENTS: Fifty-four consecutive patients (26 men; mean [+/- SD] age, 59 +/- 7 years) with complete LBBB (14 patients with left ventricular [LV] dilatation) and intermediate probability of CAD. METHODS: Simultaneous single photon emission CT scan (20 mCi technetium Tc 99m stress/rest sestamibi) and echocardiography (second harmonic imaging) during a two-step (0.56 to 0.84 mg/kg) dipyridamole infusion protocol. Two sestamibi readings were performed. The first reading considered only those studies with reversible defects (sestamibi-1) to be positive. The second reading considered those studies with any defect (sestamibi-2) to be positive. CAD was defined as a >or= 50% reduction in diameter in at least one major vessel seen on coronary angiography. RESULTS: CAD was present in 17 patients (31.5%). The global predictive accuracy for CAD was significantly higher for DSE (87.0%) and sestamibi-1 (79.6%) than for sestamibi-2 (57.4%) [p < 0.01 vs DSE; p < 0.05 vs sestamibi-1]. No significant differences in sensitivity were present, but specificity was significantly higher for DSE (94.6%) and sestamibi-1 (81.1%) than for sestamibi-2 (43.2%; p < 0.01 vs both the other two tests). Of 14 patients with LV dilatation, 26.8% were falsely positive for CAD (in some cases for posterior defects) as determined by sestamibi-1 and 64.3% were falsely positive for CAD by sestamibi-2 vs none by DSE. CONCLUSIONS: DSE is at least as accurate as dipyridamole sestamibi scintigraphy for predicting CAD in patients with complete LBBB and tends to be more specific in those patients with underlying LV dilatation.

Patent side branches do not affect coronary blood flow in internal thoracic artery-left anterior descending anastomosis: an experimental study.

BACKGROUND: It has been reported that large side branches of internal thoracic artery grafts may steal flow from the coronary circulation. Material an. METHODS: To assess the importance of the side branches, we measured the proximal and distal flow and pressures (mean subclavian artery pressure and mean arterial anastomotic pressure) at baseline and during infusion of adenosine (0.5 mg/kg/min) in 10 Landrace pigs in which an internal thoracic artery-left anterior descending anastomosis was constructed without interruption of the side branches. The difference between proximal and distal flow was considered to represent the blood flow of the internal thoracic artery side branches. Measurements were then repeated after surgical occlusion of all the side branches. RESULTS: At baseline, blood flow of the side branches represented 18% of the total flow in the proximal internal thoracic artery, and this percentage remained constant under the infusion of adenosine, which caused a 220% increase of the cardiac index and a 368% increase of the proximal flow. The infusion reduced the gradient along the left internal thoracic artery (mean subclavian artery pressure-mean arterial anastomotic pressure) from 15 to 10 mm Hg (P =.02) as the result of a lower mean subclavian artery pressure, although the mean arterial anastomotic pressure remained constant. Interruption of all the side branches resulted in a small and not significant increase in distal flow even after adenosine infusion. CONCLUSION: These observations suggest that blood flow in the side branches is minimal either at baseline and under combined systemic and coronary vasodilation. Clinically significant flow steal from the coronary circulation to the internal thoracic artery side branches seems then unlikely.

Conversion of Lap-Band to gastric bypass for dilated gastric pouch.

An 18-year-old female who had undergone a laparoscopic adjustable gastic banding developed several episodes of gastric pouch dilatation (GPD), treated conservatively. The last GPD (31 months after Lap-Band placement) involved the lesser curvature of the stomach and was refractory to medical treatment. Conversion to an open gastric bypass was performed. Gastric bypass is an option in the case of Lap-Band failure.

Laparoscopic adjustable silicone gastric banding: preliminary results of the University of Naples experience.

BACKGROUND: Laparoscopic adjustable silicone gastric banding (LASGB) is a minimally invasive surgical procedure indicated for the treatment of patients with morbid obesity. METHODS: From January 1996, eight patients successfully underwent the video-laparoscopic procedure. RESULTS: Preoperative body mass index was 44.4 +/- 4.7 (range 37.9-53.3). Mean operative time was 255 +/- 73 minutes (range 150-360). Mean hospital stay was 3 +/- 1 days. Intraoperative complications were absent. CONCLUSION: Preliminary results have been satisfactory, and encourage us to continue with LASGB.

Treatment of morbid obesity and gastroesophageal reflux with hiatal hernia by Lap-Band.

BACKGROUND: Esophageal reflux is common in obese patients. Hiatal hernia is considered a potential contraindication to placement of a Lap-Band. METHODS: Esophageal investigation in patients who were candidates for a Lap-Band included clinical evaluation of symptoms (scoring system), endoscopic and radiologic evaluation, 24-h pH test, and stationary manometry. Patients with gastroesophageal reflux (GER) with or without hiatal hernia underwent the Lap-Band procedure. RESULTS: GER was diagnosed in 12/40 morbidly obese patients, 11 of whom received a standard Lap-Band (3 patients were radiologically diagnosed with transient hiatal hernia). One patient with a large hiatal hernia underwent closure of the diaphragmatic esophageal hiatus, and the Lap-Band was positioned similarly to an Angelchik prosthesis. All but 1 patient who was lost at follow-up were symptom-free (range 1-24 months). CONCLUSION: GER with or without hiatal hernia is not a contraindication for obese patients undergoing a Lap-Band procedure. It accomplishes by a single operation satisfactory treatment of these two disturbing diseases.

Follow-up of Lap-Band complications.

BACKGROUND: Proximal gastric pouch dilation (PGPD) and band dislocation (BD) are the most frequent complications of laparoscopic adjustable silicone gastric banding (LASGB). METHODS: Conservative treatment of PGPD and BD was attempted in all patients by deflation of the band. In the case of failure, laparoscopic exploration was performed. RESULTS: From January 1996 to July 1998, 8 of 40 patients who underwent LASGB experienced PGPD (n = 7) or BD (n = 1). Debanding was performed in 3 patients with PGPD, while in 4 the pouch dilation was successfully treated with deflation of the band. Two patients (PGPD and BD) were treated with band repositioning. Weight loss was not influenced in patients treated conservatively, compared with patients who did not experience complications. CONCLUSIONS: PGPD and BD are not always responsible for band failure in LASGB. Conservative treatment can be successful, and repositioning of the band is feasible in selected cases.

Distortion of calculated whole-body hematocrit during lower-body immersion in water.

We found a difference between the venous hematocrits of immersed and nonimmersed arms during immersion of the lower body in cold water but not during a comparable exposure to warm water. Fourteen healthy men were exposed to three different experimental conditions: arm immersion, body immersion, and control. The men always sat upright while both upper extremities hung vertically at their sides. During arm immersion, one forearm was completely immersed for 30 min in either cold water (28 degrees C, n = 7) or warm water (38 degrees C, n = 7). This cold-warm water protocol was repeated on separate days for exposure to the remaining conditions of body immersion (immersion of 1 forearm and all tissues below the xiphoid process) and control (no immersion). Blood samples were simultaneously drawn from cannulated veins in both antecubital fossae. Hematocrit difference (Hct diff) was measured by subtracting the nonimmersed forearm's hematocrit (Hct dry) from the immersed forearm's hematocrit (Hct wet). Hct diff was approximately zero when the men were exposed to the control condition and body immersion in warm water. In the remaining conditions, Hct wet dropped below Hct dry (P less than 0.01, 3-way analysis of variance). The decrements of Hct diff showed there were differences between venous hematocrits in immersed and nonimmersed regions of the body, indicating that changes of the whole-body hematocrit cannot be calculated from a large-vessel hematocrit soon after immersing the lower body in cold water.

Aberrant cytokine gene expression in the hippocampus in murine systemic lupus erythematosus.

Cytokines are important mediators of immune regulation and have been implicated in the pathogenesis of the neurological disturbances, which occur in up to sixty percent of patients with systemic lupus erythematosus (SLE). SLE is an autoimmune disease characterized by the presence of autoantibodies against nuclear antigens, including native DNA. Cytokines are thought to drive autoantibody production in lupus. Certain of the derangements in memory and learning described in human and experimental SLE map to the hippocampus. The current study examines the expression of cytokine genes in the hippocampus in lupus, using MRL-lpr/lpr mice as the experimental model. These mice spontaneously develop a SLE-like illness accompanied by disturbances in spatial learning. Our results suggest a potential role for proinflammatory cytokines in the cognitive aberrations observed in lupus.

Regional influences on the physical properties of T cell membranes.

Differences in the composition of membrane lipids are well documented between cells from distinct tissues. These differences may be manifested by changes in the motional freedom or fluidity of lipid molecules within plasma membranes and may predispose to alterations in cellular function. Regional influences on immune function have been implied by the finding that thymic-derived cells from murine spleen and lymph nodes are differentially responsive to antigen priming. The possibility that microenvironment also shapes the physical properties of T lymphocyte membranes has not been explored and is the focus of this study. Using mice as the experimental model, differences were found in fluidity and in the resting level of intracellular free-ionized Ca2+ between splenic and lymph node T cells from immunologically normal mice and from autoimmune-prone MRL-lpr/lpr mice. The results indicate that T cells are more heterogeneous than previously recognized and suggest a potential role for microenvironment in determining immune responsiveness.

PTFE shunts for hemodialysis access: progressive choice of configuration.

The autologous arteriovenous fistula remains the best primary means of obtaining hemodialysis access. When this is unavailable, a prosthetic conduit must be considered. Selection of the appropriate access site has become increasingly important because of the increasing long-term survival of hemodialysis patients. A strategy is presented for sequential graft placement once revision at a given site is no longer feasible, with emphasis on efficient use of native arterial and venous structures, maximizing long-term patency, and preventing potential infectious and ischemic complications.

Giant congenital nevi: a 20-year experience and an algorithm for their management.

A variety of treatment options exists for the management of giant congenital nevi. Confusion over appropriate management is compounded because not all giant congenital nevi are pigmented, and malignant potential varies between different types. The present study sought to define factors in the presentation of giant congenital nevi that could provide an algorithm for their management, with respect to both the extent of resection and subsequent reconstructive options.A retrospective review of all patients who presented with a congenital nevus of 20 cm2 or greater since 1980 was performed, distinguishing among nevi involving the head and neck, the torso, and the extremities. Sixty-one patients with giant congenital nevi were evaluated (newborn to age 16 years), of which 60 nevi in 55 patients have been operated on. Giant congenital nevi having malignant potential were pigmented nevi (53 patients) and nevus sebaceus (four patients). Those not having malignant potential were verrucous epidermal nevi (three patients) and a woolly hair nevus (one patient). Of the 60 giant congenital nevi operated on, expanded flaps were used in 25, expanded full-thickness skin grafts were used in 10, split-thickness or nonexpanded full-thickness skin grafts were used in 13, and serial excision was used in 30. After 1989, operations tended to use multimodality treatment plans, with an increased use of expanded full-thickness grafts and immediate serial tissue expansion. The use of serial excision, particularly in the extremities, also increased after 1989. Serial excision was the treatment of choice when it could be completed in two procedures or less, which occurred in more than 80 percent of cases using serial excision alone. Expanded flaps were the most common mode of reconstruction in the head and neck region and were used in 49 percent of these procedures. Serial excision was the most common form of treatment in the extremities, used in 50 percent of procedures. Tissue expansion in the extremities was infrequently used to provide an expanded flap (8 percent of procedures), whereas it was frequently used to provide expanded full-thickness skin grafts harvested from the torso (used in 31 percent of procedures). On the basis of these data, algorithms for the extent of resection and subsequent reconstructive options for giant congenital nevi were developed. Their management should be formulated relative to pigmentation, malignant potential, and anatomic location of the respective lesions.