Initial UK experience with transversus abdominis muscle release for posterior components separation in abdominal wall reconstruction of large or complex ventral hernias: a combined approach by general and plastic surgeons.

Introduction Large, complicated ventral hernias are an increasingly common problem. The transversus abdominis muscle release (TAMR) is a recently described modification of posterior components separation for repair of such hernias. We describe our initial experience with TAMR and sublay mesh to facilitate abdominal wall reconstruction. Methods The study is a retrospective review of patients undergoing TAMR performed synchronously by gastrointestinal and plastic surgeons. Results Twelve consecutive patients had their ventral hernias repaired using the TAMR technique from June 2013 to June 2014. Median body mass index was 30.8kg/m2 (range 19.0-34.4kg/m2). Four had a previous ventral hernia repair. Three had previous laparostomies. Four had previous stomas and three had stomas created at the time of the abdominal wall reconstruction. Average transverse distance between the recti was 13cm (3-20cm). Median operative time was 383 minutes (150-550 minutes) and mesh size was 950cm2 (532-2400cm2). Primary midline fascial closure was possible in all cases, with no bridging. Median length of hospital stay was 7.5 days (4-17 days). Three developed minor abdominal wall wound complications. At median review of 24 months (18-37 months), there have been no significant wound problems, mesh infections or explants, and none has developed recurrence of their midline ventral hernia. Visual analogue scales revealed high patient satisfaction levels overall and with their final aesthetic appearance. Conclusions We believe that TAMR offers significant advantages over other forms of components separation in this patient group. The technique can be adopted successfully in UK practice and combined gastrointestinal and plastic surgeon operating yields good results.

Method for home monitoring of urinary amylase after pancreas transplantation.

Urinary amylase activity (UAA) is used for diagnosis of rejection in bladder-drained pancreas grafts. Unfortunately, most rejection episodes occur after the patient has been discharged. In those cases, an early diagnosis is often difficult, and a method for home UAA monitoring is needed. We have developed a method that can be used for this purpose. The method, based on Kodak dry-film technology, is shown to have good response to the wide range of UAA seen in these patients compared with responses to standard laboratory kinetic methods. The analysis (performed by the patient) involves 1) collecting urine for 24 h in a 4-L container, 2) diluting the urine with tap water to a total urine of 4 L, and 3) placing a drop of this dilution onto a slide. The slide is read by a handheld spectrophotometer that displays the UAA in secreted units per hour. The reliability of this system has been tested for wide changes of urine pH, volume of the drop applied to the slide, and tap water from different sources. Temperature coefficients have been determined to correct changes in ambient temperatures. The final handheld prototype is being developed based on these preliminary studies. This device could be of benefit for the early diagnosis of rejection episodes in recipients of bladder-drained pancreas grafts after hospital discharge.

Posterior subcapsular cataract in endogenous Cushing syndrome: an uncommon manifestation.

PURPOSE: Posterior subcapsular cataract is a well-known complication of longstanding glucocorticoid therapy (exogenous Cushing syndrome). The purpose of this study was to examine the effect of chronic endogenous hypercortisolism (endogenous Cushing syndrome) on the human lens. METHODS: Sixty consecutive patients (8 to 67 years of age, 46 females, 14 males) with endogenous Cushing syndrome were studied. The exposure to cortisol was estimated based on the duration of the disease and measurements of the 24-hour urine free cortisol excretion. Complete ocular examination included biomicroscopy of the lens after dilation. RESULTS: Duration from the onset of endogenous Cushing syndrome ranged from 1 to 20 years (mean +/- SD, 5.5 +/- 3.7). Urine free cortisol excretion ranged from 250 to 3065 micrograms/24 hr (mean +/- SD, 693 +/- 547; normal values, 20 to 90 micrograms/24 hr). Only two of the 60 patients (3.3%) had posterior subcapsular cataract. This low prevalence contrasts to the high prevalence attributed to glucocorticoid therapy with grossly equivalent total dosage of glucocorticoids. CONCLUSION: It was concluded that posterior subcapsular cataract is an infrequent complication of endogenous hypercortisolism compared to exogenous Cushing syndrome. Because the total exposure to endogenous glucocorticoids was not lower than that of exogenous glucocorticoid therapy, a potential explanation for this difference might be the exposure of the lens to the natural (cortisol) rather than a synthetic glucocorticoid or pharmacokinetic differences of glucocorticoids between the two forms of Cushing syndrome.

Central serous chorioretinopathy in endogenous hypercortisolism.

OBJECTIVE: To examine the potential association of central serous chorioretinopathy with endogenous hypercortisolism (Cushing's syndrome). DESIGN: Ophthalmologic survey of consecutively admitted patients with endogenous Cushing's syndrome. SETTING: An eye clinic of a research center (National Eye Institute, Bethesda, Md). PATIENTS: Sixty consecutive patients with confirmed endogenous Cushing's syndrome. MAIN OUTCOME MEASURES: Findings from complete ophthalmologic evaluation. RESULTS: Three (5%) of 60 patients had one or more episodes of appropriately documented central serous chorioretinopathy. In all cases, the episodes occurred during the period of hypercortisolism. CONCLUSIONS: Central serous chorioretinopathy is an uncommon manifestation of endogenous Cushing's syndrome. Since central serous chorioretinopathy has been associated with other hypercortisolemic states, we suggest that glucocorticoids may play a role in the development of this disease.

Legionella pneumophila serogroup 12 pneumonia in a renal transplant recipient: case report and environmental observations.

We describe the first reported case of pneumonia due to Legionella pneumophila serogroup 12 in the UK. This hospital-associated infection occurred in an immuno-incompetent patient and coincided with a change in character of the local environmental strains of legionellas. The patient produced a serological response both to her own isolate and to L. pneumophila serogroups 1-6. Thus serodiagnosis was attainable using the usual screening antigens.

Tortuosity of the retinal vessels in Aarskog syndrome (faciogenital dysplasia).

Aarskog syndrome (faciogenital dysplasia) is a genetic growth disorder characterized by short stature, cryptorchidism, shawl scrotum, and dysmorphic facial features. Ophthalmic findings include hypertelorism, blepharoptosis, strabismus, and ophthalmoplegia. The authors report a patient with Aarskog syndrome and bilateral retinal vessel tortuosity. This is the first retinal anomaly associated with Aarskog syndrome.

Prevalence of primary monofixation syndrome in parents of children with congenital esotropia.

The prevalence of primary monofixation syndrome (MFS) in the general population is approximately 1%. This study was performed to determine the prevalence of primary monofixation in biological parents of children with congenital esotropia. Ninety children with congenital esotropia were seen between November 1991 and June 1992 by one ophthalmologist (M.M.P.). One hundred and twenty-nine biological parents of these children were screened for sensorimotor abnormalities. Twelve parents were found to have secondary MFS and were removed from the analysis. This left 78 apparently non-strabismic families consisting of a total of 117 parents. Seven parents were identified as having primary MFS. The prevalence of primary MFS in this population is 9% of families and 6% of parents. Congenital esotropia is believed to be inherited in a multifactorial fashion. We believe that this increase in the prevalence of primary MFS compared to the general population lends support to the hypothesis that primary MFS may be a mild (subthreshold) effect of the "gene(s)" that cause congenital esotropia.

Retinoblastoma in the state of Oklahoma: a clinicopathologic review.

This is a retrospective review of 56 patients diagnosed with retinoblastoma (Rb) from 1970 to 1990 at either the Dean A. McGee Eye Institute or Children's Hospital of Oklahoma. Twenty-six (46%) patients had somatic Rb and thirty (54%) had germinal Rb. On average, somatic disease presented at 20.5 months and germinal disease at 11.7 months. Nine (16%) of our patients have died; of these, metastatic disease was the cause of death in six patients, whereas a midline pineal tumor (trilateral retinoblastoma) was the cause of death in three patients. Metastatic disease presented an average of 17.5 months after the diagnosis of Rb, and death occurred an average of 10.3 months after the diagnosis of metastasis. Trilateral Rb presented an average of 18 months after the diagnosis of retinoblastoma, and on average death occurred 2 months later. Histopathology was available on forty-nine of our patients. Poorly differentiated tumor histology, optic nerve invasion of tumor cells past the surgical plane of transection, and choroidal invasion of tumor cells appear to be significant histological markers for developing metastatic disease. The cytogenetics, current therapy, and related management of retinoblastoma are reviewed.

Mesenteric panniculitis in Merseyside: a case series and a review of the literature.

Mesenteric panniculitis (also known as mesenteric manifestation of Weber-Christian disease, isolated lipodystrophy and mesenteric lipogranuloma), a benign inflammatory or fibrotic change in the mesentery of the bowel, is a rare diagnosis, particularly in the UK. Some 213 cases have been reported in the world-wide literature, just six from the UK. We present four cases of mesenteric panniculitis in Merseyside and review the literature surrounding this poorly understood phenomenon. Four patients who attended surgical out-patients with vague abdominal symptoms, and in two cases a palpable mass, were sent for abdominal computed tomography (CT) scan. One patient was admitted as an emergency with abdominal pain. In each patient there were clear signs of mesenteric panniculitis, first described in 1924. The 'classical' signs of mesenteric panniculitis seen on CT have been argued by some to be pathognemonic of the disease. In two cases, the patients underwent laparoscopic biopsies to confirm the diagnosis. We discuss the literature relating to mesenteric panniculitis, theories about its aetiology, confirmation of the diagnosis and consider the possibility that it is not actually as rare as we think. We suggest that it is rather under diagnosed due to the relative ignorance of the condition amongst both surgeons and radiologists the UK compared to the US, where mesenteric panniculitis is far more widely reported.

Six models of heterotopic rat liver transplantation: introducing a reverse circulation model.

Six different models of heterotopic partial (30%) liver transplant techniques were enumerated step-by-step with the special introduction of a so-called nonregenerative model in which the afferent blood supply to the liver graft was the host's systemic blood while the reverse circulation model was to receive the host's portal blood via the suprahepatic vena cava. The reverse circulation model needs further investigation as to its applicability, but the nonregenerative partial liver transplant model certainly deserves attention because of its importance for possible infusion studies using various hepatic nutrients, hormones, and enzymes.

Intragastric balloon in the treatment of patients with morbid obesity.

BACKGROUND: Morbid obesity is a major health problem. This study evaluated the effectiveness and safety of an intragastric balloon (IGB) for the treatment of morbid obesity. METHODS: Sixty-nine IGBs were inserted endoscopically over a 3-year period in 63 consecutive patients (59 women; median age 41 (range 24-67) years). Median weight and body mass index were 124.5 (range 89.0-177.8) kg and 46.3 (range 36.2-72.4) kg/m(2) respectively. Significant coexistent disease was present in 34 patients. Median American Society of Anesthesiologists score was 3 (range 1-4). Data were recorded following retrospective review of patient case notes. RESULTS: Mean operating time was 22 (range 15-30) min and median inpatient stay was 1 (range 1-6) day. Vomiting was the commonest early complication following 31 procedures and necessitated early removal of four IGBs. Of 58 patients with long-term follow-up, 18 suffered displacement of the IGB after at least 6 months in situ and three required a laparotomy for intestinal obstruction. Fifty patients (86 per cent) lost weight; median weight loss was 15.0 kg (P < 0.001). Median excess weight loss was 16.4 (range - 49.0 to + 4.8) and 18.7 (range - 51.5 to 12.6) per cent by 4 and 7 months after IGB insertion respectively. CONCLUSION: The IGB represents a useful device for the treatment of morbid obesity, particularly in preparation for definitive antiobesity procedures. Early IGB replacement is essential to minimize complications.

Histometric investigations of the effect of cyclosporin A on the testicular tissue of rats.

The effect of cyclosporin A (CsA) on rat testes was assessed in Lewis rats which were given 10 mg/kg of CsA im per day. The rats were divided into 13 subgroups, and 1 subgroup was sacrificed each month. The rat testes were measured and examined for histometrical and morphological changes in comparison to controls. Histometrical analysis included testicular cross-sectional surface area, tubular density, tubular diameter, and the amounts of testicular germinal epithelium, lumen, and interstitial tissue. In the parameters examined, there were no overall differences between CsA-treated animals and controls. CsA does not affect rat testicular tissue.