Penetrating foreign body in the masticator space with injury to the internal maxillary artery: a surgical challenge.

INTRODUCTION Foreign bodies (FBs) in the masticator space (MS) are a unique problem because of the difficulty of accessing this deep compartment within the head and neck. In addition, MS contents include critical structures such as the internal maxillary artery (IMA) and mandibular nerve. CASE HISTORY A 39-year-old tradesman was involved in a construction accident whereby a metallic projectile from a machinery drill penetrated his left cheek. Computed tomography revealed a metallic object of dimension 1.9 ×1.2 cm within the MS, with concomitant fracture of left maxillary anterior and lateral walls. Surgery was indicated in view of constant pain and swelling. The FB was removed through the cheek laceration with the aid of an X-ray image intensifier. Persistent significant bleeding was observed within the wound cavity after FB removal that could not be arrested despite attempts at haemostasis with adrenaline packing and oxidised cellulose polymers. Urgent selective left external carotid angiography showed breach of a distal branch of the left internal maxillary artery with contrast extravasation. Embolisation of this branch was undertaken successfully with a liquid agent. CONCLUSIONS This is the first time a FB within the MS with injury to the internal maxillary artery has been described.

Malignant mesonephric tumor of the cervix with an initial manifestation as pulmonary metastasis: case report and review of the literature.

Malignant mesonephric tumor (MMT) is a relatively uncommon malignancy of the female genital tract. The diagnosis of metastatic MMT is difficult because cytological, pathological, immunohistochemical characteristics of MMT are under-recognized. The authors present a 55-year-old female with metastatic pulmonary nodules. The bronchial washing cytology revealed three dimensional clusters of bland epithelial cells with slight nuclear grooves. A corresponding lung histology had ductal or tubular clusters of epithelial cells with intraglandular eosinophilic materials. These epithelial cells were positive for immunohistochemical stain of CD10, suggesting metastasis from MMT. The cervical smear showed clusters of bland, gland-forming epithelial cells with intraglandular eosinophilic materials. On histologic examination, mesonephric adenocarcinoma with papillary and solid proliferation was identified in the uterine cervix. A review of the literature for 72 cases of MMT is also included. Clinical and cytopathological features of MMT are herein made available.

A reappraisal of functional reconstruction of extension of the knee following quadriceps resection or loss.

The current indications for functional restoration of extension of the knee following quadriceps resection or loss require reappraisal. The contribution of pedicled and free functional muscle transfer is likely to be over-emphasised in many studies, with good functional outcomes predominantly reported only in the context of cases with residual quadriceps function. In cases with total quadriceps resection or loss, all forms of reconstruction perform poorly. Furthermore, in smaller resections with loss of two or fewer components of the quadriceps, minimal impairment of function occurs in the absence of functional reconstruction, suggesting that functional restoration may not be warranted. Thus there is a paradox in the current approach to quadriceps reconstruction, in that small resections are likely to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and rationale for reconstructing functional extension of the knee after quadriceps resection or loss. A classification based on current evidence is suggested that emphasises more clearly the indications and rationale for functional transfers.

Factors predicting deviation from an enhanced recovery programme and delayed discharge after laparoscopic colorectal surgery.

AIM: The study aimed to identify factors that predict postoperative deviation from an enhanced recovery programme (ERP) and/or delayed discharge following colorectal surgery. METHOD: Data were prospectively collected from all patients undergoing elective laparoscopic colorectal resection between January 2006 and December 2009. They included Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) variables, body mass index (BMI), sex, preoperative serum albumin, pathology, conversion from a laparoscopic to an open approach and postoperative length of hospital stay. RESULTS: There were 176 patients (90 women) of mean age 68 years. Fifteen (9%) operations were converted from laparoscopic to open. The remainder were completed laparoscopically. Fifty-five (31%) deviated from the ERP, with most failing multiple elements. The most common reason was failure to mobilize, which often occurred in conjunction with paralytic ileus or analgesic failure. Factors independently predicting ERP deviation on multivariate analysis were pathology and intra-operative complications. The median length of stay was 5 days. Sixty-four (36%) patients had a prolonged length of stay that was predicted by age, number of procedures and ERP deviation. CONCLUSION: Pathology and intra-operative complications are independent predictors of ERP deviation. Prolonged length of stay can be predicted by age, multiple procedures and ERP deviation. Failure to mobilize should be considered as a red flag sign prompting further investigation following colorectal resection.

Duloxetine reduces morphine requirements after knee replacement surgery.

BACKGROUND: Multimodal analgesia is advocated for perioperative pain management to reduce opioid use and its associated adverse effects. Serotonin and norepinephrine are involved in the modulation of endogenous analgesic mechanisms via descending inhibitory pain pathways in the brain and spinal cord. An increase in serotonin and norepinephrine may increase inhibition of nociceptive input and improve pain relief. Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor, has demonstrated efficacy in chronic pain conditions such as painful diabetic neuropathy and post-herpetic neuralgia. The objective of the study was to evaluate the efficacy of duloxetine in reducing morphine requirements in patients after knee replacement surgery. METHODS: Fifty patients received either two doses of oral duloxetine 60 mg (2 h before surgery and on first postoperative day) or placebo. All patients received patient-controlled analgesia with morphine for 48 h after operation. Pain and adverse effects were assessed at 0.5, 1, 2, 6, 12, 24, and 48 h after surgery on an 11-point numeric rating scale. RESULTS: Twenty-three patients in the duloxetine group and 24 patients in the placebo group completed the study. Morphine requirements during the 48 h after surgery were significantly lower in the duloxetine group [19.5 mg, standard deviation (sd) 14.5 mg] compared with the placebo group (30.3 mg, sd 18.1 mg) (P=0.017). There were no statistically significant differences between the groups in pain scores (at rest and on movement) or in adverse effects. CONCLUSIONS: Perioperative administration of duloxetine reduced postoperative morphine requirements during the first 48 h after knee replacement surgery, without significant adverse effects.

Management of gamma nail breakage with bipolar hemi-arthroplasty.

Gamma nail breakage is an uncommon occurrence that often arises from fatigue failure of the implant, with a reported incidence ranging from 0.2 to 5.7 percent. We report a 73-year-old woman with a three-part intertrochanteric fracture and who presented two years postoperatively with gamma nail failure secondary to fracture non-union. This patient underwent a revision long-stem bipolar hemi-arthroplasty and has been followed-up for 24 months, with good functional and radiological results.

The effects of daily irradiation with polychromatic visible polarized light on human lymphocyte populations.

OBJECTIVE: The goal of this randomized, placebo controlled, double-blind study was to investigate the effects of transcutaneous irradiation with polychromatic visible polarized light (540-780 nm; 68% polarization; power density 3.0 E-10 W/cm(2)) on a subset population of human lymphocytes using flow cytometry. BACKGROUND DATA: The biomodulation and therapeutic effects of visible light of different wavelengths are well known, but the immunological effects of polychromatic visible polarized light have not been investigated sufficiently. METHODS: Before and after 28 consecutive days of irradiation, blood samples were collected from the subjects and the population count of the lymphocyte subset was measured. RESULTS: The absolute count of total lymphocytes, CD3(+) lymphocytes, and CD3(+)CD4(+) lymphocytes increased by 7% (p = 0.023), 9% (p = 0.058), and 13% (p = 0.021), respectively. Yet the absolute count of WBCs, CD3(+)CD8(+), CD19(+), and CD16(+)56(+) lymphocytes did not change significantly. CONCLUSION: The application of polychromatic visible polarized light with the aforementioned features increases the CD3(+)CD4(+) lymphocyte population. It is suggested that this regimen may be useful for the promotion of natural defenses in cell-mediated immunity.

Novel action of gastric proton pump inhibitor on suppression of Helicobacter pylori induced angiogenesis.

BACKGROUND: Although activation of mitogen activated protein kinases (MAPKs) by Helicobacter pylori infection is associated with induction of host angiogenesis, which may contribute to H pylori associated gastric carcinogenesis, the strategy for its prevention has not been identified. As we previously reported a strong inhibitory action of gastric proton pump inhibitors (PPIs) on MAPK extracellular signal regulated kinase (ERK)1/2 phosphorylation, we investigated whether PPIs could suppress the H pylori induced angiogenesis via inhibition of MAPK ERK1/2. METHODS: To address the relationship between H pylori infection and angiogenesis, comparative analysis of density of CD34(+) blood vessel was performed in tissues obtained from 20 H pylori positive gastritis and 18 H pylori negative gastritis patients. Expression of hypoxia inducible factor 1 (HIF-1alpha) and vascular endothelial growth factor (VEGF) was tested by reverse transcription-polymerase chain reaction and secretion of interleukin 8, and VEGF was measured by ELISA. To evaluate the direct effect of H pylori infection on the tubular formation of human umbilical vein endothelial cells (HUVEC), an in vitro angiogenesis assay was employed. Activation of MAPK and nuclear factor kappaB (NFkappaB) was detected by immunoblotting. RESULTS: H pylori positive gastritis patients showed a higher density of CD34(+) blood vessels (mean 40.9 (SEM 4.4)) than H pylori negative gastritis patients (7.2+/-0.8), which was well correlated with expression of HIF-1alpha. Conditioned media from H pylori infected gastric epithelial cells directly induced tubular formation of HUVEC and the increase of in vitro angiogenesis was suppressed by PPI treatment. Infection of H pylori significantly upregulated expression of HIF-1alpha and VEGF in gastric epithelial cells and expression of proangiogenic factors was mediated by MAPK activation and partially responsible for NFkappaB activation. PPIs effectively inhibited the phosphorylation of MAPK ERK1/2 that is a principal signal for H pylori induced angiogenesis. CONCLUSIONS: The fact that PPIs could downregulate H pylori induced angiogenesis indicates that antiangiogenic treatment using a PPI could be a promising protective therapeutic approach for H pylori associated carcinogenesis.

Membrane blebbing during apoptosis results from caspase-mediated activation of ROCK I.

The execution phase of apoptosis is characterized by marked changes in cell morphology that include contraction and membrane blebbing. The actin-myosin system has been proposed to be the source of contractile force that drives bleb formation, although the biochemical pathway that promotes actin-myosin contractility during apoptosis has not been identified. Here we show that the Rho effector protein ROCK I, which contributes to phosphorylation of myosin light-chains, myosin ATPase activity and coupling of actin-myosin filaments to the plasma membrane, is cleaved during apoptosis to generate a truncated active form. The activity of ROCK proteins is both necessary and sufficient for formation of membrane blebs and for re-localization of fragmented DNA into blebs and apoptotic bodies.

Substance use by indigenous and non-indigenous primary school students.

OBJECTIVE: Recent Australian research with adolescents aged 13 to 17 years has found that Indigenous youth are more likely than non-Indigenous adolescents to smoke tobacco and cannabis, although they may be less likely to use alcohol. The objective of this study was to examine whether this pattern exists among younger children. METHOD: A school-based, self-report survey was conducted in primary schools that had high proportions of Aboriginal and Torres Strait Islander children. Four schools were located in metropolitan Brisbane and three in Far North Queensland (sample n = 507 students: 270 girls, 237 boys, aged 9-13 years). RESULTS: Significant numbers of these children had started to experiment with recreational drugs. Twenty-two per cent had attempted to smoke at least one cigarette, 14% smoked in the preceding year, while 3% had smoked more than 10 cigarettes in their lives. Thirty-eight per cent had had at least one drink of alcohol, while 6% had smoked marijuana at least once. There was no significant association between Indigenous/non-Indigenous background and risk of smoking tobacco or marijuana, while Indigenous children were less likely than non-Indigenous children to report experience with alcohol. CONCLUSIONS: Contrary to data from secondary school students, Indigenous youth in primary schools were not more likely than non-Indigenous children to have experimented with tobacco or marijuana, or to be frequent tobacco smokers. It appears therefore that the excessive uptake of drug use among Indigenous youth occurs in the early stages of secondary school. This finding underlines the importance of preventive education in primary schools, especially for Indigenous children who have a high risk of making the transition to drug use in adolescence.

The skeletal response to matt and polished cemented femoral stems.

We studied the effect of the surface finish of the stem on the transfer of load in the proximal femur in a sheep model of cemented hip arthroplasty. Strain-gauge analysis and corresponding finite-element (FE) analysis were performed to assess the effect of friction and creep at the cement-stem interface. No difference was seen between the matt and polished stems. FE analysis showed that the effects of cement creep and friction at the stem-cement interface on femoral strain were small compared with the effect of inserting a cemented stem.

Role of caspase-3 in apoptosis of colon cancer cells induced by nonsteroidal anti-inflammatory drugs.

Epidemiological studies have demonstrated that nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the incidence of and mortality from colon cancer. In addition, NSAIDs reduce the number and the size of polyps in patients with familial adenomatous polyposis. The mechanisms responsible for the antineoplastic effect of NSAIDs are not yet completely understood, but one of the possible mechanisms is an induction of apoptosis. We explored the role of caspase-3, a major apoptosis-executing enzyme, in NSAID-induced apoptosis of colon cancer cell line HT-29. Treatment of HT-29 cells with indomethacin induced a dramatic increase in caspase-3-like protease activity measured by a cleavage of the fluorogenic substrate Ac-DEVD-AMC. Western blot analysis showed that indomethacin treatment led both to decrease in procaspase-3 and to cleavage of its substrate poly(ADP-ribose) polymerase (PARP). Furthermore, the caspase-3-like protease inhibitor Ac-DEVD-CHO attenuated indomethacin-induced DNA fragmentation dose dependently. However, mRNA expression of CASP genes was not affected by the addition of indomethacin, highlighting the importance of posttranslational modification of this enzyme for the activation. These results suggest that NSAIDs, including indomethacin, induce apoptosis in colon cancer cells through a caspase-3 dependent mechanism which may contribute to the chemopreventive functions of these agents.

Predictors of hysterectomy: an Australian study.

OBJECTIVE: We evaluated the relative importance of predictors of hysterectomy. STUDY DESIGN: A questionnaire survey of an Australia-wide sample of adult female twins was conducted; self-report data were validated against reports from treating physicians. RESULTS: A total of 3096 women (94%) and 366 physicians (87%) responded. The sensitivity of patient report of hysterectomy was 98.2%. Best predictors of hysterectomy were endometriosis (odds ratio 4.85, 95% confidence interval 3.17-7.43), medical consultation for menorrhagia (odds ratio 3.55, 95% confidence interval 2.47-5.12), joint effects of fibroids with medical consultation for chronic or persisting pelvic pain (odds ratio 3.34, 95% confidence interval 1. 42 to 7.87), having smoked >40 cigarettes per day (odds ratio 3.24, 95% confidence interval 1.10-9.55), joint effects of fibroids with consultation for menstrual problems (odds ratio 2.61, 95% confidence interval 1.36-5.01), and tubal ligation (odds ratio 1.77, 95% confidence interval 1.31-2.39). Less-important predictors were age and higher education level (protective). CONCLUSION: Consulting a physician about pelvic pain and menstrual problems, especially heavy bleeding, are recognized steps toward hysterectomy. Of particular interest for future genetic analyses are the high odds of hysterectomy for women with endometriosis, fibroids, or menorrhagia.

Ecthyma gangrenosum in a patient with hypogammaglobulinemia.

Ecthyma gangrenosum is a characteristic skin lesion that is caused by Pseudomonas aeruginosa (P. aeruginosa) in the majority of cases. Systemic P. aeruginosa usually complicates debilitating conditions like leukaemia, burns and cystic fibrosis. We report a patient with underlying hypogammaglobulinemia who developed ecthyma gangrenosum secondary to P. aeruginosa septicaemia, which was potentially life-threatening. Recognition of the characteristic skin lesions with prompt initiation of appropriate antibiotics and intravenous immunoglobulins were life-saving. A review of the English literature reports three other cases of ecthyma gangrenosum in patients with underlying hypogammaglobulinemia.

Epidemiological surveillance of melioidosis in Singapore.

During the period 1989 to 1996, a total of 372 cases of melioidosis, with 147 deaths, were reported, giving a mean annual incidence rate of 1.7 per 100,000 population and a case-fatality rate of 39.5%. Majority (89%) of the clinical cases were confirmed by culture of Burkholderia pseudomallei, while the others were presumptive cases based on a single blood specimen with an indirect haemaglutination (IHA) antibody titre of > or = 1:16. The highest incidence rate was reported in those aged 45 years and above (5.7 per 100,000 population), males (2.8 per 100,000 population), and Indian ethnic group (3.0 per 100,000 population). Cases were distributed throughout the island all year round. There was no correlation with rainfall. Most of the cases (77.4%) had other concurrent medical conditions, the most common being diabetes mellitus (57.5%). Factors significantly associated with a higher case-fatality rate were age (55 years and above), septicaemia, smoking history and heart or renal failure. The overall case-fatality rate has been declining from 60% in 1989 to 27% in 1996 due to a greater awareness among medical practitioners to diagnose and treat the disease early. The overall seroprevalence of IHA antibody (titre of > or = 1:16) among asymptomatic population groups was 0.2%. B. pseudomallei isolated from clinical specimens were sensitive to imipenem (100%), ceftazidime (99.1%), piperacillin (99.7%), ampicillin-clavulanate (98.5%), minocycline (97.4%), chloramphenicol (94.3%), doxycycline (94.3%) and tetracycline (93.9%). Of 395 samples of soil collected during epidemiological investigation of reported cases, 1.8% were positive for B. pseudomallei.

Somatic mutations in the p53 tumor suppressor gene in rheumatoid arthritis synovium.

The factors that regulate the perpetuation and invasiveness of rheumatoid synovitis have been the subject of considerable inquiry, and the possibility that nonimmunologic defects can contribute to the disease has not been rigorously addressed. Using a mismatch detection system, we report that synovial tissue from the joints of severe chronic rheumatoid arthritis patients contain mutant p53 transcripts, which were not found in skin samples from the same patients or in joints of patients with osteoarthritis. Mutant p53 transcripts also were identified in synoviocytes cultured from rheumatoid joints. The predicted amino acid substitutions in p53 were identical or similar to those commonly observed in a variety of tumors and might influence growth and survival of rheumatoid synoviocytes. Thus, mutations in p53 and subsequent selection of the mutant cells may occur in the joints of patients as a consequence of inflammation and contribute to the pathogenesis of the disease.

Apoptosis in rheumatoid arthritis: p53 overexpression in rheumatoid arthritis synovium.

DNA damage induces p53 tumor suppressor gene expression and protein production, which in turn facilitates DNA repair or apoptosis. Wild-type p53 protein has a short half-life, so it is rarely detected in non-neoplastic tissue. Because DNA fragmentation is abundant in the intimal lining in rheumatoid arthritis (RA) synovial tissue (ST) using in situ end-labeling (Firestein GS, Yeo M, Zvaifler NJ: Apoptosis in rheumatoid arthritis synovium. J Clin Invest 1995, 96:1631-1638), we assessed ST p53 expression. Immunohistochemical analysis of fixed RA synovium using antibody PAb 1801 showed prominent p53 staining in the cytoplasm and nuclei of intimal lining cells. Noninflammatory and osteoarthritis (OA) ST had significantly less p53 in the lining. These data were confirmed by Western blot analysis of ST extracts, with abundant p53 found in RA compared with OA. p53 expression in cultured fibroblast-like synoviocytes (FLS) was then examined. Flow cytometry on permeabilized cells showed that RA FLS constitutively express p53 protein. Western blots showed that RA FLS expressed significantly more p53 than either OA FLS or dermal fibroblasts. Immunohistochemistry of FLS cultured in chamber slides localized the p53 to the cytoplasm of most resting FLS, with nuclear staining in only 10.7 +/- 2.4%. Exposure to hydrogen peroxide for increased nuclear staining to 70.7 +/- 12.8% after 8 hours (P = 0.003). These data indicate that p53 is overexpressed in RA ST in the intimal lining, which is the primary site of DNA damage, and is constitutively expressed by FLS.

Apoptosis in rheumatoid arthritis synovium.

RA synovial tissue (ST) was studied to determine if and where apoptosis occurs in situ. Genomic DNA was extracted from 5 RA and 1 osteoarthritis ST samples. Agarose gel electrophoresis demonstrated DNA ladders characteristic for apoptosis from each tissue. In situ and labeling (ISEL) was used to identify DNA strand breaks consistent with apoptosis in frozen sections. 12 RA and 4 osteoarthritis ST were studied by ISEL and all were positive, but only 2 of 4 normal tissues were positive. The primary location of apopotic cells was the synovial lining. Some sublining cells were also positive, but lymphoid aggregate staining was conspicuously absent. Immunohistochemistry and ISEL were combined and showed that the lining cells with DNA strand breaks were mainly macrophages, although some fibroblastlike cells were also labeled. Sublining cells with fragmented DNA included macrophages and fibroblasts, but T cells in lymphoid aggregates, which expressed large amounts of bcl-2, were spared. DNA strand breaks in cultured fibroblastlike synoviocytes was assessed using ISEL. Apoptosis could be induced by actinomycin D, anti-fas antibody, IL-1, and TNF-alpha but not by IFN-gamma. Fas expression was also detected on fibroblast-like synoviocytes using flow cytometry. Therefore, DNA strand breaks occur in synovium of patients with arthritis. Cytokines regulate this process, and the cytokine profile in RA (high IL-1/TNF; low IFN-gamma) along with local oxidant injury might favor induction of apoptosis.

Molecular cloning of a cardiotoxin structural gene from Malayan spitting cobra (Naja naja sputatrix).

The structural gene and cDNA encoding cardiotoxin in Naja naja sputatrix have been cloned and characterized with a view to study the gene protein relationships and also to produce pure protein in large amounts. Using the polymerase chain reaction on the total RNA isolated from the venom glands, the structural gene (180 bp) has been synthesized and expressed in Escherichia coli to produce a fusion protein with beta-galactosidase. Immunoblotting using polyclonal antibodies raised against the total venom in rabbits demonstrated the presence of cross-reacting proteins in plaques produced by recombinant lambda gt11 phages.