Post-liver transplant leptin results in resolution of severe recurrence of lipodystrophy-associated nonalcoholic steatohepatitis.

We describe the first case of a patient undergoing orthoptic liver transplantation for acquired generalized lipodystrophy-related nonalcoholic steatohepatitis who developed severe recurrence of nonalcoholic fatty liver disease in the first few months posttransplant but responded rapidly to the administration of exogenous leptin. The beneficial effects of therapy were supported by histology along with magnetic resonance spectroscopy studies, which demonstrated that leptin therapy greatly reduced fat deposition in the liver. Leptin therapy may have a role to play in preventing patients with lipodystrophy developing end-stage liver disease or in rescuing such patients who develop disease recurrence postliver transplantation.

Cerebral microhemorrhage and brain ß-amyloid in aging and Alzheimer disease.

OBJECTIVES: Incidental cerebral microhemorrhage (MH) is frequently found in older individuals scanned with susceptibility-weighted MRI (SWI) or gradient-recalled echo MRI. MH have been linked with ß-amyloid (Aß) deposition using (11)C-Pittsburgh compound B (PiB) PET in Alzheimer disease (AD) and cerebral amyloid angiopathy (CAA). We hypothesized that Aß deposition in asymptomatic elderly individuals is associated with lobar MH (LMH). METHODS: This was a cross-sectional study of 84 elderly healthy controls (HC), 28 subjects with mild cognitive impairment (MCI), and 26 subjects with probable AD who underwent 3-T SWI and (11)C-PiB PET. (11)C-PiB cortical binding was quantified normalized to cerebellar cortex (standardized uptake value ratio [SUVR]) and scans classified as positive (PiB+) or negative (PiB-) by visual inspection. MH were manually counted and categorized by region and as lobar or nonlobar. RESULTS: LMH were present in 30.8% of AD, 35.7% of MCI, and 19.1% of HC. The prevalence of LMH among PiB+ subjects was similar, regardless of clinical classification (AD 30.8%, MCI 38.9%, HC 41.4%, p > 0.7). HC with LMH had significantly higher mean neocortical SUVR (1.7 ± 0.5) than HC without LMH (1.3 ± 0.3, p ± 0.01). In HC, there was a positive correlation between number of LMH and SUVR, and between LMH and age. In HC, PiB+ (odds ratio [OR] 7.3, 95% confidence interval [CI] 1.6-33.7, p = 0.01) and age (OR 1.2, 95% CI 1.03-1.3, p = 0.02) both independently predicted the occurrence of LMH using logistic regression. CONCLUSION: Asymptomatic Aß deposition in older adults is strongly associated with LMH.

The neural architecture of discourse compression.

Re-telling a story is thought to produce a progressive refinement in the mental representation of the discourse. A neuroanatomical substrate for this compression effect, however, has yet to be identified. We used a discourse re-listening task and functional magnetic resonance imaging (fMRI) to identify brain regions responsive to repeated discourse in twenty healthy volunteers. We found a striking difference in the pattern of activation associated with the first and subsequent presentations of the same story relative to rest. The first presentation was associated with a highly significant increase in blood oxygen level dependent (BOLD) signal in a bilateral perisylvian distribution, including auditory cortex. Listening to the same story on subsequent occasions revealed a wider network with activation extending into frontal, parietal, and subcortical structures. When the first and final presentations of the same story were directly compared, significant increments in activation were found in the middle frontal gyrus bilaterally, and the right inferior parietal lobule, suggesting that the spread of activation with re-listening reflected an active neural process over and above that required for comprehension of the text. Within the right inferior parietal region the change in BOLD signal was highly correlated with a behavioural index of discourse compression based in re-telling, providing converging evidence for the role of the right inferior parietal region in the representation of discourse. Our findings demonstrate, for the first time, the existence of a neural network underlying discourse compression, showing that parts of this network are common to re-telling and re-listening effects.

Management of an unexpected appendiceal neoplasm.

BACKGROUND: Appendiceal neoplasms are rare and most present unexpectedly as acute appendicitis. The classification and management are confusing, and there are few substantial reports in the literature. METHODS: A systematic literature review was performed to access relevant publications on the presentation, pathology and management of appendiceal tumours. RESULTS: Appendiceal tumours account for 0.4 to 1 per cent of all gastrointestinal tract malignancies and are found in 0.7 to 1.7 per cent of appendicectomy specimens. Carcinoid tumours are most common. Most are cured by simple appendicectomy if the tumour is less than 2 cm in size and does not involve the resection margin or mesoappendix. Epithelial tumours may present with, or in time develop, pseudomyxoma peritonei, the optimal management of which involves complete tumour resection and intraperitoneal chemotherapy, usually available only in specialized centres. CONCLUSION: Suggested algorithms for the management of unexpected appendiceal tumours are provided. Recommendations are made for follow-up of patients with a perforated appendiceal epithelial tumour.

Rectal cancer in the elderly: patients' perception of bowel control after restorative surgery.

OBJECTIVE: The risk of incontinence is perceived as a relative contraindication to a sphincter-saving procedure in elderly patients with rectal cancer. To investigate this, we reviewed functional results one year after restorative surgery in patients older than aged 75 years. METHODS: A total of 186 patients older than aged 75 years were diagnosed with rectal cancer during the study period. In 19 patients, no surgery was undertaken, and another 3 patients had a defunctioning stoma only. A local excision was performed in six patients. Of the remaining 158 having a major resection, 133 patients (84 percent) had a restorative anterior resection. The one-year, follow-up records of these patients were studied with particular reference to the patients' perception of bowel function and continence. RESULTS: At one year, 99 patients who had had an anterior resection were alive. In 92 patients, a stoma had been closed or avoided altogether, and these patients formed the study group. Significant problems with bowel function or continence were denied by 78 of 92 patients (85 percent). One patient had already reported severe difficulties and been given a definitive stoma for incontinence. The remaining 14 percent, although experiencing some problems with continence, did not consider the situation serious enough to contemplate a stoma. CONCLUSIONS: An elderly patient undergoing anterior resection for rectal cancer has a reasonable expectation of acceptable continence. Age alone should not be a contraindication to a restorative resection.

Surgical decisions in the elderly: the importance of biological age.

Surgeons will sometimes advise against an operation because the patient is 'old and frail'. A simple starring system (one to five), based on performance and lifestyle, has been devised to assess the biological age of elderly patients. 10 consultant surgeons and 10 trainees answered questions about their treatment recommendations for hypothetical patients of standard age and medical history but with various star ratings and surgical conditions. 1000 decisions were available for analysis. The four and five star patients (those leading an independent existence) were recommended 266 interventions, the one and two star patients 55. Trainees were more inclined to intervene than consultants, recommending operations in half the patients rather than one-third. These results indicate that decisions on surgical management are strongly influenced by the patient's star rating or biological age. If the starring method proves reproducible in other patient groups and settings, it could allow better communication on an important factor in clinical decisions.

Isolation and characterization of the cell-surface polysaccharides of Porphyromonas gingivalis ATCC 53978.

The cell-surface carbohydrates of Porphyromonas gingivalis strain ATCC 53978 were isolated and partially characterized. Three separate polysaccharides were found to be present: an extracellular polysaccharide, capsular polysaccharide and lipopolysaccharide. The capsular polysaccharide, which had peculiar, gel-like viscoelastic properties, was found to be comprised of mannuronic acid, glucuronic acid, galacturonic acid, galactose, and 2-acetamido-2-deoxy-D-glucose in relative molar ratios of 0.6:0.9:0.5:0.5:1.0, respectively. The extracellular polysaccharide was found to contain mannose, rhamnose, glucose, galactose, and 2-acetamido-2-deoxy-D-glucose in relative molar ratios of 13.5:1.4:1.0:2.0:1.0, respectively. The lipopolysaccharide was found to contain an O-antigen with a regular tetrasaccharide repeat unit comprised of 4-linked alpha-L-rhamnopyranosyl, 6-linked alpha-D-glucopyranosyl, 3-linked alpha-D-galactopyranosyl, and 4-linked 2-acetamido-2-deoxy-beta-D-glucopyranosyl residues in equimolar proportions.

Hematomas and limb skeletal malformations in chicken embryos following exposure to 5-fluoro-2-deoxyuridine.

Vascular injury or interruption may play a role in vertebrate limb teratogenesis. Since 5-fluoro-2'-deoxyuridine (FdU) can cause vascular injury in the murine limb and skull prior to the appearance of skeletal malformations in these structures, we studied the effects of this chemical on skeletal development in the chick embryo and noted any vascular injury. The yolk sacs of day three chick embryos (Hamburger and Hamilton states 17-19) were injected with solutions of vary concentrations of FdU in saline. The embryos developed until the 10th day of incubation when they were fixed for study. Uninjected, saline injected, and sham injected control embryos were similarly fixed. Upon gross inspection, frequent diffuse and saccular hematomas, as well as fluid-filled blisters, were noted in the limbs of embryos treated with FdU. After the embryos were fixed and cleared, and the skeletons stained, significant skeletal malformations were observed in these limbs. Bony elements of both the upper and lower limbs were affected in at least some of the embryos. The combination of FdU-induced hematomas and blisters with associated skeletal malformations in the same regions of some embryos suggests a relationship between these phenomena.

Wound infection following high saphenous ligation. A trial comparing two skin closure techniques: subcuticular polyglycolic acid and interrupted monofilament nylon mattress sutures.

A prospective, randomized trial was performed to compare the incidence of wound infection following skin closure with subcuticular polyglycolic acid and interrupted monofilament nylon mattress sutures in patients undergoing high saphenous ligation (126 patients; 75 polyglycolic acid wounds, 86 interrupted monofilament nylon mattress wounds). By 6 weeks after operation, pus had discharged from 15 (20%) polyglycolic acid wounds compared with seven (8%) interrupted monofilament nylon mattress wounds (P = 0.05), giving an overall infection rate of 13.7%. Infection occurred in 23% of the 56 procedures performed by the two surgeons with the highest infection rates compared with 8% of the 105 procedures performed by the remaining nine surgeons (P = 0.02). The excess of infections in wounds closed with subcuticular polyglycolic acid was caused by an excess of infections in operations performed by the two surgeons with the highest infection rates. The higher infection rate found with subcuticular polyglycolic acid appeared to be operator dependent.

Time-resolved resonance raman spectroscopy of hemoglobin derivatives: heme structure changes in 7 nanoseconds.

Resonance Raman spectra of oxyhemoglobin, deoxyhemoglobin, carboxyhemoglobin, and the corresponding myoglobin derivatives have been obtained with 7-nanosecond laser pulses at 531.8 nanometers. The results suggest that no transient constraint of the heme group by the globin structure occurs on this time scale, and thus establish a temporal sequence for the early events that may participate in the stereochemical trigger mechanism of hemoglobin cooperativity.

Growth patterns and nutrition in Nepali children.

A growth survey of four groups of Nepali children from birth to 12 years was undertaken and the growth patterns related to diet. The patterns are those of children suffering from malnutrition in the second and third year and not those of a genetically small race. Diet histories showed inadequacies of diet, mostly preventable, occurring during the same period. Privileged children within the groups showed a different pattern and a significantly better growth.