Abdominal actinomycosis after laparoscopic cholecystectomy: a rare complication of bile spillage.

BACKGROUND: Abdominal actinomycosis has not been reported after elective cholecystectomy. METHODS: Case report and review of the pertinent English-language literature. CASE REPORT: A 69-year-old man with abdominal actinomycosis presented with an abdominal mass mimicking a malignant tumor two years after laparoscopic cholecystectomy. Investigation revealed the likely source of infection to be bile spillage during surgery. CONCLUSION: This is the first reported case of abdominal actinomycosis probably attributable to bile spillage during laparoscopic cholecystectomy.

Basal cell carcinoma does metastasize.

Basal cell carcinoma (BCC) rarely metastasizes. However, this unfortunate outcome can occur, usually in neglected tumors. We report a 52-year-old man with a BCC on the left chest that enlarged and then ulcerated over a 6-year period. Metastasis of the tumor to lymph nodes in the left axilla resulted, but the patient remains free of disease 24 months after wide excision, lymph node dissection, and local radiation therapy to the axilla.

Comparative evaluation of the efficacy and safety of two doses of terbinafine (500 and 1000 mg day(-1)) in the treatment of cutaneous or lymphocutaneous sporotrichosis.

The aim of this study was to evaluate the safety and efficacy of oral terbinafine (500 and 1000 mg day(-1)) in the treatment of cutaneous or lymphocutaneous sporotrichosis. A culture for Sporothrix schenckii was required for inclusion into this multicentre, randomized, double-blind, parallel-group study. Patients received either 250 mg b.i.d. or 500 mg b.i.d. oral terbinafine for up to a maximum of 24 weeks and were assessed up to 24 weeks post-treatment. The main efficacy outcome measure was cure, defined as no lesion and absence of adenopathy at the end of follow-up. Adverse events (AEs), laboratory tests, vital signs and ophthalmological examinations were also assessed. Sixty-three patients (14-85 years of age) were treated with 500 mg day(-1) (n = 28) or 1000 mg day(-1) terbinafine (n = 35). The majority of patients were cured after 12-24 weeks of treatment, and the response was dose-dependent throughout the study and at the end of follow-up. The cure rate was significantly higher in patients treated with 1000 mg day(-1) terbinafine compared with those treated with 500 mg day(-1) terbinafine (87% vs. 52%, respectively; P = 0.004). There were no cases of relapse after 24 weeks of follow-up in the 1000 mg day(-1) terbinafine group, compared with six relapses in the terbinafine 500 mg day(-1) group. Terbinafine was well tolerated and the frequency of drug-related AEs was slightly higher in the 1000 mg treatment group. Both doses of terbinafine were well-tolerated and effective for the treatment of sporotrichosis. The 1000 mg day(-1) terbinafine dose was more efficacious than 500 mg day(-1) in the treatment of cutaneous or lymphocutaneous sporotrichosis.

Pattern of breast cancer among white-American, African-American, and nonimmigrant west-African women.

This study reviews the current understanding of the pattern of breast cancer among whites, African Americans, and West Africans who have never immigrated to the US to find better ways of improving the prevention, early detection, and care of breast cancer world-wide. In the United States, the behavior pattern of breast cancer in African-American women differs from that of white women. Among the three populations, breast cancer appears to be least common in nonimmigrant West-African women. The peak incidence in African Americans and West Africans occurs around the premenopausal period while it occurs postmenopausal period in whites. Also, unlike white women, West-African and African-American women present late for treatment with a greater cancer burden and consequently lower survival rates. The predominant histological type is infiltrating ductal carcinoma in the three groups but the highest percentage (33%) of infiltrating poorly differentiated anaplastic carcinoma occurs in West Africans. Menstrual and obstetric history, obesity, and high body mass index status appear to be greater specific risk factors among African Americans than among West Africans. African Americans and West Africans have three "Ls" in common: late stage in seeking treatment, lower age at peak incidence with severe tumor burden, and consequently lower survival rates. There is a need for more detailed population-based research at molecular levels to elucidate the basis for some of these features.

In vitro metabolism of ceftiofur in bovine tissues.

The metabolism of ceftiofur in bovine kidney, liver, muscle and lung, and the effects of the presence of cystine and glutathione in the media were evaluated using S-9 and microsomal tissue fractions. Conversion of ceftiofur to desfuroylceftiofur (DFC) was catalyzed by an esterase which was most active in kidney, followed by liver. It was not very active in muscle and lung. After DFC was liberated, it rapidly bound primarily to tissue proteins (> 56%), and was also conjugated to cysteine and glutathione. Production of DFC-cysteine by disulfide exchange of DFC with cystine and production of DFC-glutathione by conjugation of DFC to glutathione occurred in buffer if glutathione and cystine were present in the medium. These conjugations were also observed in incubations with tissue fractions, indicating that they were not inhibited by the tissues endogenous molecules. In addition, the metabolism of DFC-glutathione to DFC-cysteine was observed when tissue proteins were present. The metabolism of DFC-glutathione to DFC-cysteine was faster in kidney than in liver. Metabolites devoid of an intact beta-lactam ring were not observed in these in vitro studies.

Bacteriology of inflamed and uninflamed epidermal inclusion cysts.

OBJECTIVE: To determine whether inflamed and uninflamed epidermoid cysts differ in the number and/or type of bacteria inhabiting them. DESIGN: A controlled study. We obtained aerobic and anaerobic bacterial culture specimens from 25 inflamed and 25 uninflamed epidermoid cysts. SETTING: A university medical center. PATIENTS: Nonimmunocompromised adults without recent systemic use of antibiotics. RESULTS: The 2 groups did not differ significantly with respect to number of bacterial isolates, "no growth" cultures, and aerobic, anaerobic, or potential pathogens cultured. CONCLUSIONS: The microbiological milieu of inflamed epidermoid cysts is similar to that of uninflamed cysts. Possible mechanisms for inflammation are discussed.

Occurrence of Cowpea Stunt Disease Causing Viruses on Wild Bean in Arkansas.

Cucumber mosaic cucumovirus (CMV) and blackeye cowpea mosaic potyvirus (BlCMV) interact synergistically in dually infected plants to cause cowpea stunt disease (1,2). During a July 1996 survey of cowpea stunt-affected fields in the Arkansas River valley, several wild bean (Strophostyles helvola L. Elliott) plants expressing mosaic symptoms were observed and collected. Sap was extracted from symptomatic leaves and used as inoculum to conduct a host range study. Virus symptoms diagnostic for BlCMV, CMV, or cowpea stunt were observed 6 to 8 days post-inoculation on Vigna unguiculata (L.) Walp. subsp. unguiculata cv. Coronet, while chlorotic lesions and mild systemic mosaic symptoms developed on Nicotiana benthamiana. Enzyme-linked immunosorbent assays (ELISAs) conducted on extracts from symptomatic cowpea and N. benthamiana 14 days after inoculation verified the presence of CMV and BlCMV in single and mixed infections. Additional symptomatic wild bean plants were collected from the same site in October 1996. ELISAs and Ouchterlony gel diffusion assays confirmed the presence of CMV and BlCMV, as well as soybean mosaic potyvirus (SMV), cowpea chlorotic mottle bromovirus, and alfalfa mosaic virus (AlMV) in symptomatic wild bean plants. While some of the collected plants were infected with only one virus, others had combined infections of CMV and BlCMV or these two viruses with AlMV. Interestingly, AlMV isolated from wild bean caused symptoms on greenhouse-grown cowpeas that were as severe or more severe than those caused by the cowpea stunt synergy, often resulting in plant death within 8 to 10 days after inoculation. The SMV from wild bean did not induce symptoms on cowpea and was not detected in extracts from inoculated cowpea plants by Ouchterlony gel diffusion assays, but was able to systemically infect soybean (Glycine max L.) cvs. Bragg and Lee. Another virus known to infect cowpea, southern bean mosaic sobemovirus, was not detected in any of the samples tested. To our knowledge, this is the first report that wild bean can serve as an alternate host for cowpea stunt-causing viruses in single and mixed infections. In addition, these data suggest that AlMV may pose a threat to Arkansas-grown cowpeas. References: (1) E. J. Anderson et al. Ark. Farm Res. 43:14, 1994. (2) G. Pio-Ribeiro et al. Phytopathology 68:1260, 1978.

Enhancement of hepatitis C virus NS3 proteinase activity by association with NS4A-specific synthetic peptides: identification of sequence and critical residues of NS4A for the cofactor activity.

The NS3 proteinase of hepatitis C virus utilizes NS4A as a cofactor for cleavages at four sites (3/4A, 4A/4B, 4B/5A, and 5A/5B) in the nonstructural region of the viral polyprotein. To characterize NS4A for its role in modulating the NS3 proteinase activity at various cleavage sites, synthetic peptides spanning various parts of NS4A were synthesized and tested in a cell-free trans-cleavage reaction using purified NS3 proteinase domain and polyprotein substrates. The NS3 proteinase domain was expressed in Escherichia coli, purified, denatured, and refolded to an enzymatically active form. We found that a 12-amino-acid peptide containing amino acid residues 22 to 33 in NS4A (CVVIVGRIVLSG) was sufficient for cofactor activity in NS3-mediated proteolysis. The peptide enhanced the cleavage at the NS5A/5B site and was necessary for NS3-mediated cleavage at NS4A/4B and NS4B/5A. Sequential amino acid substitution within the designated peptide identified residues I29 and I25 as critical for potential cofactor activity. We provide evidence that the NS4A peptide and the NS3 catalytic domain form an enzymatically active complex. These data suggest that the central 12-amino-acid peptide (aa 22-33) of NS4A is primarily important for the cofactor activity through complex formation with NS3, and the interaction may represent a new target for antiviral drug development.

Health-care reform and its impact on African-American surgical specialists.

Since 1960, numerous concepts of health-care reform have been submitted to the US Congress and the American public with different viewpoints and objectives. The priority for the US Congress to pass a bipartisan health-reform plan has been circumvented by the newly elected majority Republican Congress. Nevertheless, health-care cost containment, quality control, and health-care delivery concepts have been implemented gradually into the concept of competitive managerial health care. A few of the serious problems in the African-American community are the efficiency and quality of the health-care delivery system and the effects of managed care on African-American primary physicians and surgical specialists. The critical shortages of this group, especially the latter, may create a dilemma in the implementation of a quality surgical care delivery system. The Association of American Medical Colleges, the American College of Surgeons, and other affiliating organizations should become sensitized to the African-American community's health needs, deficiencies, and the rational institution of an equitable, efficient, comprehensive, and quality health-care plan coupled with a sustained and increasing supply of certified, diversified, and experienced African-American surgical manpower in company with family practice physicians and primary care physicians.

Suppression by mycophenolate mofetil of the neointimal thickening caused by vascular injury in a rat arterial stenosis model.

Injury of the rat carotid artery by gentle perfusion of air causes vascular thickening, similar to that seen in the clinic setting in humans after percutaneous angioplasty or bypass surgery to repair injured or diseased blood vessels. In the animal model as well as in patients, this stenosis appears to be the result of smooth muscle cell migration and proliferation. Various cell types in the lesion area may contribute by producing inflammatory cytokines, adhesion molecules and growth factors. In the present study, mycophenolate mofetil (MMF), an inosine monophosphate dehydrogenase inhibitor with antiproliferative and immunosuppressive properties, was tested for its ability to inhibit this process. With a daily oral dose of 30 mg MMF/kg started 6 days before injury to one carotid artery by air perfusion, MMF reduced cross-sectional areas of total vessel wall (intima-media) thickness by 17% to 25% and of neointimal thickness by 48% to 60% at 14 days after injury in four tests (P < .001 when MMF- and vehicle-treated groups were compared for these thickened areas, n = 29 or 30). In addition, intima/media ratios ranged from 0.26 +/- 0.03 to 0.46 +/- 0.04 for MMF-treated vs. 0.55 +/- 0.05 to 0.93 +/- 0.08 for vehicle-treated animals in the four different tests (P < .001). Starting MMF treatment at either 14 or 0 days before arterial injury made no difference in the degree of reduction, suggesting that any biological process that might be altered by MMF is not one that requires much time to become established. Intima/media ratios were 0.31 +/- 0.04 or 0.34 +/- 0.04 for MMF-treated vs. 0.55 +/- 0.05 or 0.65 +/- 0.07 for vehicle-treated animals (P < .001 for day 14 or 0, respectively, n = 30). Thus, MMF reduced the vascular thickening after carotid artery injury in rats, suggesting that this class of compound may be able to control the pathological processes that lead to restenosis.

Economic issues for African-American surgical specialists in solo or group practices.

This clinical research plan was designed to evaluate the predictable and current developments, growth, and stability of the economic status of part-time or full-time African-American practicing surgeons. In many communities throughout the United States, the economic successes of certified or experienced black surgical specialists are inhibited or modified by mistrust, jealousy, professional disengagements, prejudices, and self-hatred by black and white physicians and lay African Americans. Nevertheless, there are subtle and overt evidences of increasing satisfactory and above average associative interprofessional relationships between African-American physicians and surgical specialists. One hundred African-American surgical specialists from thirty-four communities in the United States were interviewed at periodic intervals over a period of three decades. Recommendations for improvements and changes are presented.

Gout masquerading as rheumatoid vasculitis.

A 30-year-old Mexican woman had rash, deep ulcerations of her lower extremities, and debilitating polyarthritis. Her disorder simulated rheumatoid vasculitis, but serum rheumatoid factor was absent. The diagnosis of gout was confirmed by uric acid crystals in joint fluid and skin biopsy specimens and by x-ray crystallography. The age and sex were unusual for a patient with gout, and she had none of the commonly associated metabolic defects. This unique presentation for urate arthropathy needs further study.

Vaccinating guinea pigs with recombinant glycoprotein D of herpes simplex virus in an efficacious adjuvant formulation elicits protection against vaginal infection.

Guinea pigs were immunized with glycoprotein gD-2t in SAF-m or saline, then challenged with herpes simplex virus, type 2 (HSV-2). Animals given gD-2t in SAF-m had higher anti-gD-2t antibodies, fewer and less severe vaginal lesions, and decreased ganglionic latency compared to animals given gD-2t in saline. Leucocytes from animals vaccinated with gD-2t in SAF-m had greater proliferative responses to gD-2t in vitro than cells from control animals. MHC II-restricted, gD-2t-specific cytotoxic T cells were induced in guinea pigs vaccinated with gD-2t in SAF-m. Thus, immunization of guinea pigs with gD-2t in SAF-m markedly reduced the incidence and severity of primary HSV-2 by eliciting both humoral and cell-mediated responses.

Modulation of doxorubicin efficacy in P388 leukemia following co-administration of verapamil in mini-osmotic pumps.

Co-administration of doxorubicin and verapamil in Alzet mini-osmotic pumps increased the survival of B6D2F1 mice bearing the multidrug-resistant P388/ADR leukemia. A range of doxorubicin and verapamil combinations was studied to define dose-dependent efficacy and toxicity. High doses of doxorubicin (10 mg/kg/day) and verapamil (150 mg/kg/day) could be administered alone without any effect on survival. However, combining high doses of these two agents resulted in host toxicity. Doxorubicin doses of 1 to 10 mg/kg/day in combination with verapamil at 25-100 mg/kg/day were found to improve survival compared with either agent alone. Combination therapy also improved the survival of mice bearing the drug-sensitive P388/0 leukemia when compared to anthracycline treatment alone. The efficacy of the mini-osmotic pump delivery protocol was compared with other regimens delivering the same total cumulative dose of doxorubicin via repeated i.p. injections.

Fibrin degradation products in growth stimulatory extracts of pathological lesions.

We have previously shown that similar patterns of fibrin degradation products (FbDP) by gel electrophoresis and immunoblotting are present in extracts of human atherosclerotic plaques, human and experimental wounds and breast cancers. Such extracts were also shown to stimulate cell proliferation including angiogenesis in the chick chorioallantoic membrane, now shown also for breast cancers. Removal of FbDP from plaque extracts by an anti-fibrinogen affinity column, or by an anti-fragment E column, reduced activity. Human FbDP prepared in vitro were active, but not FgDP. Fibrin fragment E was active, and we also showed that admixture of FbDP with a polyclonal rabbit anti-fibrin E but not anti-fibrin D neutralized activity. However attempts to raise comparable monoclonal blocking antibodies were hindered by species similarities. The response of the Balb/c mouse was predominantly directed at minor D contaminants, in contrast to the Sprague-Dawley rat which responded to fibrin fragment E in our antigen preparation.

Fibrinogen and atherosclerosis.

Fibrin appears to be a multi-potential component of atherogenesis, intervening at virtually all stages of lesion development. Fibrin and microthrombus deposition on normal intima is associated with endothelial disruption and intimal oedema, and oedema is a primary characteristic of early proliferative lesions. Fibrin strands on or in the intima encourage smooth muscle cell (SMC) migration and proliferation, and contribute to the growth of plaques. Fibrin also provides a continuing source of fibrin degradation products (FDP), and these have mitogenic activity which will sustain SMC proliferation in growing plaques, and act as chemoattractants for blood leucocytes. Accumulation of the lipid core in fibrous plaques may also be influenced by fibrin which appears to bind the lipoprotein Lp(a) with high affinity, thereby immobilizing its lipid moiety within the lesion.

Complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy with lasers or cautery is a feasible, effective, and worthwhile operative procedure that is subject to morbidity and mortality. There is unequivocal evidence that the complication incidence is directly related to the training and experience of the surgeon, applicability of basic principles of gallbladder and common duct surgery, and preventive measures toward iatrogenic injuries in gallbladder surgery. Continued and sustained investigation in laparoscopic cholecystectomy, technological developments in equipment, and the continued education of the surgeon in the applicability and use of laparoscopic cholecystectomy, intraoperative cholangiography, and choledocholithotomy are essential. At the St Francis Medical Center, Pittsburgh, Pennsylvania 1009 laparoscopic cholecystectomies with lasers or cautery were performed between March 1989 and October 1991. There were 32 (3%) abandoned laparoscopic cholecystectomies with alternative open cholecystectomy. There were six extrahepatic ductal injuries and a complication incidence of 10.9%. The mortality rate was 0.38%. The average length of stay was 2 days. In comparison with standard cholecystectomy, laparoscopic cholecystectomy is a competitive and superior procedure in selected circumstances.

Surgical results and complications in elderly patients with benign lesions of the spinal canal.

OBJECTIVE: To describe the long-term outcome and complications of spinal surgery in a population of elderly patients. DESIGN: Retrospective chart review and clinical follow-up. SETTING: A 700-bed tertiary care midwestern hospital. PATIENTS: Patients 70 years of age or older who underwent elective surgical procedures for the treatment of benign lesions of the spinal canal. MAIN OUTCOME MEASURES: Data obtained from chart review included age, sex, nature and duration of neurological symptoms, activities of daily living (ADL), associated illnesses, length of hospitalization, type of surgery, and complications attributable to surgery. Outcome measurements included changes in neurological symptoms and ADL and a standardized scale obtained from consecutive outpatient visits, telephone interviews, or written responses. RESULTS: Seventy-eight patients with lumbar canal stenosis or soft disc herniations underwent laminectomies, foraminotomies or discectomies. Eleven patients underwent cervical laminectomies for multilevel spondylitic myelopathy. Limb and spine pain were the most common neurological symptoms in patients with lumbar lesions; diminished ADLs were present in eight patients with cervical myelopathies. Six patients died of unrelated causes, and 78 were followed for an average of 27.1 months. Twenty-three (85.2%) of 27 patients with lumbar disc herniations reported improvements or resolution of limb pain while 35 (81.4%) of 43 patients with lumbar canal stenosis reported fair or good results. Five of eight patients with multilevel cervical spondylosis reported improvements of myelopathic symptoms. Twenty-six (28.6%) complications were attributable to 91 surgical procedures including five severe complications and one fatality. Patients with three or more associated illnesses demonstrated a significantly higher incidence of postoperative complications. CONCLUSIONS: Elderly patients with benign lesions of the spinal canal may achieve significant reduction in limb pain and increases in ADL following appropriate surgery, with a tolerable rate of severe complications. The preoperative physical condition of the elderly patient served as an indicator for operative morbidity.