Isolation and molecular characterisation of Halicephalobus gingivalis in the brain of a horse in Piedmont, Italy.

BACKGROUND: A fatal case of meningoencephalitis was reported in a 13-year-old Koninklijk Warmbloed Paard Nederland stallion, suspected of West Nile virus (WNV) infection, in the Piedmont region of Italy. Clinical signs included right head tilt and circling, depression alternated with excitability, fever and lateral strabismus. Combined treatment consisting of dimethylsulfoxide, dexamethasone, sulphonamides and sedative was administered, but because of the poor conditions the horse was euthanatized and submitted for necropsy. RESULTS: At post-mortem examination no skin lesions were observed, all organs appeared normal on gross evaluation and only head and blood samples were further investigated. Neuropathological findings consisted of granulomatous meningoencephalitis and larvae and adult females of Halicephalobus gingivalis were isolated and identified from the digested brain. Frozen brain was submitted to PCR amplification and 220 bp multiple sequence alignment was analysed by Bayesian phylogenetic analysis. CONCLUSIONS: Phylogenetic inference revealed that the isolate belongs to H. gingivalis Lineage 3. WN surveillance can help to deepen our knowledge of horse neurological disorders investigating their causes and incidence. Moreover, it can help to understand the geographic distribution of the H. gingivalis, to unravel epidemiological information, and to estimate risk for humans.

A new method of jejunal reconstruction after pancreaticoduodenectomy.

Although advances in pancreatic surgery have reduced mortality rates, post-operative morbidity remains a frequent problem in patients undergoing pancreaticoduodenectomy. The single most significant cause of morbidity in these patients is the development of pancreatic fistula. In this study, we assessed the occurrence of pancreatic fistula after isolated Roux loop pancreaticojejunostomy with the use of a haemostatic collagen-fibrin patch (TachoSil) to prevent pancreatic leakage. A total of 27 patients (15 men and 12 women, mean age 59 years, range 19-74 years) underwent proximal Whipple-type resection. Ten patients underwent a classical pancreaticoduodenectomy while a pylorus-preserving pancreaticoduodenectomy was performed in the other 17 patients. Reconstruction was done using three-jejunal anastomosis, with TachoSil applied at the end of the pancreatic jejunal anastomosis, along the entire anastomotic circumference. None of the 27 patients who underwent pancreaticoduodenectomy developed pancreatic fistula. One patient had bleeding from the gastro-jejunal anastomoses, five patients had infections of surgical sites, and three patients developed bacterial pneumonia. There were no significant differences in duration of surgery or intra-operative blood loss between patients with soft or hard pancreatic tissue. The reconstruction technique described here with three independent jejunal loops appears to offer good protection against pancreatic leakage.

Management and outcome of pouch-vaginal fistulas following restorative proctocolectomy.

PURPOSE: The aim of this study was to assess the short-term and long-term outcomes of surgical repair of patients with pouch-vaginal fistulas after restorative proctocolectomy. METHODS: A descriptive study was undertaken of all patients developing pouch-vaginal fistulas following restorative proctocolectomy between 1978 and 2003 in a single tertiary referral institution. Kaplan-Meier survival analysis was used to evaluate the time to first pouch-vaginal fistula recurrence and pouch-vaginal fistula-free survival at last follow-up. RESULTS: Sixty-eight patients (mean age, 32.2 years; standard deviation, 10.7) were identified with a median follow-up of 5.5 (range, 0.2-25.5) years. The origin of the pouch-vaginal fistulas was the pouch-anal anastomosis in 52 (76.5 percent) patients, pouch body/top in 9 (13.2 percent), or cryptoglandular or other source in 7 (10.3 percent). Associated early complications in patients with pouch-vaginal fistulas included pelvic sepsis in 20 (29 percent) patients, anastomotic separation in 6 (24 percent), anastomotic stricture in 16 (24 percent), small bowel obstruction in 17 (25 percent), hemorrhage in 2 (3 percent), or pouchitis in 12 (18 percent). Surgery was undertaken in 59 (87 percent) patients with 14 (20.6 percent) of them undergoing pouch excision/diversion or seton drainage. Forty-five (66 percent) patients underwent primary repair. First recurrence of pouch-vaginal fistula occurred in 27 of 45 (60 percent) patients with a median pouch-vaginal fistula-free interval of 1.6 years (95 percent confidence interval, 0.6-2.7). Fourteen (51.9 percent) patients with recurrent pouch-vaginal fistulas healed following one or more repeat procedures. The diagnosis of Crohn's disease was made in eight (12 percent) patients, with pouch-vaginal fistulas persisting or recurring in all patients with Crohn's disease within five years of the primary treatment. Median pouch-vaginal fistula-free survival was 1.4 years for patients with Crohn's disease and 8.1 years for patients with ulcerative colitis or familial adenomatous polyposis. The pouch-vaginal fistula-free survival improved with repeated local or abdominal repairs for patients with ulcerative colitis. The overall pouch failure rate for patients with pouch-vaginal fistulas was 35 percent (median pouch survival, 4.2 years). CONCLUSIONS: Pouch-vaginal fistulas can persist and recur indefinitely, even after repeated repairs. Repair in those patients with Crohn's disease uniformly failed within five years from primary repair. Patients with recurrent pouch-vaginal fistulas and ulcerative colitis should be offered salvage surgery because successful closure following initial failure occurs in approximately 50 percent.