What is the best method of rectovaginal fistula repair? A 25-year single-center experience.

BACKGROUND: The surgical treatment of rectovaginal fistula (RVF) remains challenging and there is a lack of data to demonstrate the best, single procedure. The aim of this study was to assess the results of different surgical operations for rectovaginal fistula. METHODS: Patients with RVF who underwent surgical repair between 1992 and 2017 at a single, tertiary care center were included. Twenty different procedures were performed including: primary closure, closure with sphincter repair, flap repairs, plug/fibrin/mesh repair, examination under anesthesia (EUA) ± seton placement, abdominal resections with and without diversion and ileostomy takedown, gracilis muscle transposition, fistulotomy/ligation of intersphincteric fistula tract. All patients with RVF due to diverticulitis and patients without complete data from paper charting were excluded. Success was defined based on the absence of symptoms related to RVF and absence of diverting stoma at 6 months. RESULTS: One hundred twenty-four women were analyzed. The median age was 45 (range 18-84) years. Median follow-up time from the last procedure was 6 months (range 0-203 months). The total number of patients considered successfully treated at the end of their treatment was 91 (91/124, 73.4%). When considering all procedures (n = 255), the success rate for flap procedures was 57.9% (22/38), followed by abdominal resections with and without proximal diversion and ileostomy takedown (16/29, 55.2%) and primary closure with sphincter repair (17/32, 53.1%) while fistula plug, and fibrin glue had among the lowest success rates (4/22, 18.2%). The highest success rate was observed among patients whose RVF etiology was due to malignancy (11/16, 68.8%) followed by unknown (8/14, 57%) and iatrogenic (21/48, 43.8%) causes. CONCLUSIONS: Local procedures such as mucosal flap or primary closure and sphincteroplasty are associated with a high success rate should be considered in patients with low-lying, simple RVF. Abdominal resections with and without proximal diversions and ileostomy takedown have a relatively high success rate in selected patients. The low success rate of fibrin glue and fistula plugs demonstrates their low efficacy in RVF; thus, these procedures should be avoided in the treatment algorithm.

Bilateral adrenal hemorrhage after colectomy for perforated diverticulitis: A case report.

INTRODUCTION: Bilateral adrenal hemorrhage can lead to acute adrenal insufficiency. This is a rare complication in the post-operative setting, and we present a case in which it developed after a colectomy for perforated diverticulitis. PRESENTATION OF CASE: The patient is a 65-year-old female who presented with abdominal pain, nausea, emesis, and hematochezia, and CT scan showing sigmoid diverticulitis with peri-sigmoid abscess. After a failure of non-operative treatment, she underwent Hartmann's resection, and her post-operative course was complicated by refractory tachycardia, hypotension, hyponatremia, and nausea/vomiting. Bleeding, hypovolemia, and sepsis were ruled out. A CT scan showed enlarged poorly defined adrenals bilaterally, suggestive of bilateral adrenal hemorrhage. Serum cortisol level was low and diagnostic of acute adrenal insufficiency. With intravenous steroid therapy (hydrocortisone), her vital signs, laboratory abnormalities, and diet intolerance all resolved. She was discharged on oral prednisone and continued long term. DISCUSSION: Bilateral adrenal hemorrhage is rare post-operatively and can lead to adrenal insufficiency. 15% of patients who die in shock have bilateral adrenal hemorrhage on autopsy, indicating the necessity of timely diagnosis and treatment of this condition. Corticosteroid therapy is the mainstay of treatment. CONCLUSION: This case study illustrates that post-operative delay of progression or worsening of condition, with no alternative explanation, can be due to acute adrenal insufficiency resulting from bilateral adrenal hemorrhage, and timely diagnosis and treatment of this condition is paramount for a favorable outcome.

Gene expression profile is associated with chemoradiation resistance in rectal cancer.

AIM: Patients with rectal cancer who achieve a complete pathological response after preoperative chemoradiation (CRT) have an improved oncological outcome. Identifying factors associated with a lack of response could help our understanding of the underlying biology of treatment resistance. This study aimed to develop a gene expression signature for CRT-resistant rectal cancer using high-throughput nucleotide microarrays. METHOD: Pretreatment biopsies of rectal adenocarcinomas were prospectively collected and freshly frozen according to an institutional review board-approved protocol. Total tumour mRNA was extracted and gene expression levels were measured using microarrays. Patients underwent proctectomy after completing standard long-course CRT and the resected specimens were graded for treatment response. Gene expression profiles for nonresponders were compared with those of responders. Differentially expressed genes were analyzed for functional significance using the Ingenuity Pathway Analysis (IPA) software. RESULTS: Thirty-three patients treated between 2006 and 2009 were included. We derived 812-gene and 183-gene signatures separating nonresponders from responders. The classifiers were able to identify nonresponders with a sensitivity and specificity of 100% using the 812-gene signature, and sensitivity and specificity of 33% and 100% using the 183-gene signature. IPA canonical pathway analysis revealed a significant ratio of differentially expressed genes in the 'DNA double-strand break repair by homologous recombination' pathway. CONCLUSION: Certain rectal cancer gene profiles are associated with poor response to CRT. Alterations in the DNA double-strand break repair pathway could contribute to treatment resistance and provides an opportunity for further studies.

Rapid isolation of genomic DNA from animal tissues.

A simple technique for the isolation of very high molecular weight genomic DNA from animal tissues and cells is described. The method involves rapid isolation of nuclei and their embedding in agarose beads followed by extraction of lipids and proteins with SDS. The protocol does not require proteolytic digestion and the whole procedure can be completed in 1 day. The isolated DNA is digestible by restriction enzymes and free of ligase inhibitors.

Cutaneous squamous cell carcinoma characteristics.

The second most common type of skin cancer, squamous cell carcinoma, carries a higher mortality rate than basal cell carcinoma. This article discusses the incidence, risk, characteristics, and prevention of the disease.

Etretinate. Persistent serum levels after long-term therapy.

In 47 patients who received long-term etretinate therapy, we measured serum etretinate concentrations from one to 244 weeks after the discontinuation of therapy. The earliest posttreatment, nondetectable serum concentration of etretinate was observed at five weeks after treatment. Detectable serum concentrations (0.05 to 1.2 micrograms/dL) were observed more than two years (108, 111, 131, 136, and 150 weeks) following the discontinuation of therapy. Sequential serum concentrations obtained on eight individual patients were used to determine half-lives for this late-phase elimination. The median half-life for the 12 curves obtained was 12.5 weeks (range, 5.3 to 24.8 weeks). Since etretinate is stored in fat, we compared each patient's deviation from ideal body weight as a measure of excess body fat with various pharmacokinetic factors of etretinate elimination. Overweight patients tended to have slower elimination, maintain higher serum concentrations, and clear etretinate later.

Expression of myelin protein genes in quaking mouse brain.

The expression of myelin proteins in actively myelinating quaking and control brains was studied. RNA was extracted from the brains of 18- and 27-day-old mice and analyzed by northern blot using cDNA probes for proteolipid protein (PLP), basic protein (BP), and myelin-associated glycoprotein (MAG). Two PLP transcripts of 3.2 and 2.4 kb (kilobase) were found, whereas PB and MAG probes hybridized to single regions of 2.2 and 2.5 kb, respectively. No abnormality in the transcript pattern was detectable in the quaking brain at either 18 or 27 days of age. Over this 9-day period the level of PLP and BP message in the control brain decreased by approximately 10%, whereas the level of MAG message decreased by approximately 50%. In the 18-day-old quaking brain the expression of PLP and BP was severely reduced amounting to one-third and one-half of the control values, respectively. The reduction at the age of 27 days was less. On the other hand, the quaking brain produced more MAG mRNA amounting to 1.6- and 3.2-fold control on the 18th and 27th day. The results indicate a reduced expression of the PLP and BP genes and a developmental delay in the mutant, whereas the genetic expression of MAG is enhanced and appears to be progressively dysregulated.

Distribution of calcium-activated neutral proteinase activity in quaking mouse brain: a subcellular study.

The distribution of calcium-activated neutral proteinase (CANP) activity was examined in the subcellular fractions of quaking and control mouse brain. The CANP activity was determined in purified myelin, cytosol and pellet (P2, consisting of nuclei, mitochondria and microsomes) fractions using [14C]azocasein as substrate. The enzyme activity in quaking brain was 1.3-fold greater than control. Fifty-seven percent of the control brain activity was in purified myelin compared to only 7% in quaking myelin. The specific activity of the control purified myelin was 4-fold greater than homogenate while that of the quaking was two-fold greater. In contrast, 51% of the quaking brain activity was present in cytosol compared to only 18% in the control. Triton X-100 greatly increased the control brain activity (10-fold) while the quaking brain activity was increased by only 1.2-fold. The total calcium content in the quaking brain was greatly elevated (6-fold) compared to control. Approximately 30% of the brain 2',3'-cyclic nucleotide 3'-phosphohydrolase (CNPase) activity was in quaking myelin while 77% of the CNPase activity in control brain was in myelin. These results suggest that in quaking brain much of the CANP is not incorporated into the myelin membrane and remains cytosolic.

Reduced anxiety and depression in cystic acne patients after successful treatment with oral isotretinoin.

We evaluated the psychiatric morbidity and mood characteristics of a group (n = 72) of patients with cystic acne before and after treatment with one of three dosage schedules of isotretinoin. Although no excess psychiatric morbidity was observed, substantial evidence of psychologic distress was noted before treatment. Significant reductions in anxiety were observed on several measures of anxiety after treatment, with mitigation of anxiety and depression most robust in those patients with the greatest dermatologic improvement with isotretinoin.

Increased turnover of myelin proteolipid protein in quaking mouse brain.

Homozygous quaking and normal control littermate mice were injected intracerebrally with [3H]leucine at 19 days of age. The animals were sacrificed after 1 h and after 6 days. The proteolipid protein (PLP) and intermediate protein (IP) were extracted from whole brain by chloroform-methanol (2:1) and resolved by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). One hour postinjection the labeling of total protein in quaking brain was the same as the control and the radioactivity of PLP and IP in quaking was approximately 35% of the control. Six days after precursor administration the radioactivity of the total protein decreased significantly in both groups and to the same extent. However, the labeling of PLP and IP more than doubled in the control, while it decreased by half in the quaking brain. The results indicate that there is an increased turnover rate of PLP and IP in quaking brain.

Abnormal glycosylation of myelin-associated glycoprotein in quaking mouse brain.

Brain slices from actively myelinating (26-28 days) quaking and normal littermates were dual-labeled with radioactive mannose and fucose for 2 h. Following the incubation myelin was isolated by sucrose density gradient centrifugation and the incorporation of sugars into the major myelinassociated glycoprotein (MAG) determined. The incorporation of mannose (an internal monosaccharide) and fucose (a terminal monosaccharide) was impaired in quaking by approximately 70 and 83% respectively as compared to control. The mannose/fucose ratio in quaking myelin was approximately 70% higher than in control. The results indicate an abnormal processing of the N-linked oligosaccharide moiety of MAG in quaking oligodendrocytes.

Synthesis and acylation of myelin proteolipid protein in quaking mouse brain.

The synthesis and acylation of proteolipid proteins where investigated in tissue slices prepared from 19-day-old quaking and normal littermate mouse brain. The mutant CNS had a normal rate of total protein synthesis but synthesis of the myelin-specific proteins, proteolipid protein (PLP) and intermediate protein (IP), was impaired to approximately 50% of control. The acylation of myelin proteins with labeled palmitate was reduced to only about 20% of control. The acylation of two nonmyelin proteolipid proteins was also significantly reduced. The incorporation of palmitate into phospholipids was identical in control and mutant. The results indicate impaired synthesis of PLP and IP and a general deficit in protein acylation in quaking brain.

Peroxidative aggregation of myelin membrane proteins.

The exposure of CNS myelin to reactive oxygen species (ROS) generated by a Cu2+-H2O2 system results in the aggregation of membrane proteins. Integral and peripheral membrane proteins are equally vulnerable and the denaturation is not mediated by the SH groups. The aggregated proteins retain their original antigenicity as determined by immunoblot technique. The aggregation of proteins is not limited to myelin and can be elicited in the preparation of other cerebral membranes. The effect of ROS on membrane proteins can also be demonstrated in cerebral slices incubated in the presence of the ROS-generating system. Furthermore, the peroxidation inactivates membrane-bound enzymes as exemplified by myelin cyclic nucleotide phosphatase (CNP). Competitive inhibition studies with various scavengers and quenchers of ROS implicate singlet oxygen as a major mediator in the Cu2+-H2O2 oxidizing system responsible for the peroxidative aggregation of membrane proteins.

Acylation of myelin proteolipid protein in subcellular fractions of rat brainstem.

The acylation of myelin proteolipid protein (PLP) and intermediate protein (IP) was investigated in an in vitro system of tissue slices prepared from actively myelinating rat brainstem. The incorporation of [(3)H]palmitate into the proteins in nine subcellular fractions including myelin and other cellular membranes which are actively involved in the synthesis and intracellular transport of the proteins was measured. More than 80% of [(3)H]palmitate-labeled proteins were recovered in myelin. The incorporation was highest in the heavy myelin and lowest in the light myelin subfraction. Appreciable acylation was also detected in the myelin-like fraction. On the other hand, the remaining fractions comprising a variety of endo- and ectomembranes, which harbored over 90% of newly synthesized PLP and IP as seen from [(3)H]leucine labeling showed practically no [(3)H]palmitate incorporation. The results indicate that the acylation of PLP and IP is a late event in their posttranslational processing and occurs only at their entry into the myelin sheath.

Minocycline-associated tooth discoloration in young adults.

After observing a patient with adult-onset tooth discoloration coincident with minocycline administration, we retrospectively surveyed a cohort of patients with severe cystic acne during therapeutic trials with isotretinoin. Four of 72 patients who had minocycline therapy during adolescence were found to have minocycline-associated tooth discoloration, which occurred in one case after only four weeks of treatment. Thus, minocycline must be considered as an uncommon cause of tooth staining in adults.

Etretinate: effect of milk intake on absorption.

Since etretinate, an aromatic retinoid useful in the treatment of psoriasis and other skin disorders is lipid-soluble, it may be poorly absorbed in the absence of a fat load. We therefore studied serum concentrations of etretinate and its major metabolite (Ro 10-1670) after the controlled administration of etretinate. After an overnight fast, 6 Darier's disease and 4 psoriatic patients received a 1 mg/kg morning dose of etretinate with water or 1 pint of whole milk (fat load). There was a 260% increase (p less than 0.0005) in the mean of each patient's increase in the baseline-corrected peak serum concentration of etretinate after administration with milk (115 +/- 15 micrograms/dl) compared to after administration with water (32 +/- 4 micrograms/dl). Over a 24-h period there was an overall 296 +/- 26% (p less than 0.0005) increase in serum etretinate after administration with milk compared to water in 5 patients with Darier's disease. In contrast to the serum etretinate, there was a 17% mean decrease (p less than 0.025) in the corrected peak serum concentration of Ro 10-1670 in all 10 patients after administration of etretinate with milk compared to water. The net result of these alterations is that the mean corrected serum concentration of etretinate is higher than Ro 10-1670 at all time points measured after milk administration. In contrast, after administration of etretinate with water the major retinoid in the serum is Ro 10-1670. Establishing the clinical significance of these alterations may require controlled clinical trials.

Basic proteins of rodent peripheral nerve myelin: immunochemical identification of the 21.5K, 18.5K, 17K, 14K, and P2 proteins.

Proteins in peripheral nervous system and central nervous system myelin and homogenates of sciatic nerve and brain from young and adult mice and rats were characterized with affinity-purified anti-P2 and anti-myelin basic protein sera after electrophoretic transfer from sodium dodecyl sulfate-polyacrylamide gels to nitrocellulose sheets. Using this method we have identified a component of rodent peripheral nervous system myelin as P2 protein. Peripheral nervous system myelin also showed the presence of four basic proteins in addition to P2 protein. These were found to be analogous to the 14, 17, 18.5, and 21.5K species found in the central nervous system myelin. A number of high-molecular-weight proteins were also detected with anti-myelin basic protein serum in peripheral nervous system, as well as central nervous system myelin. In addition, we report the presence of a high-molecular-weight P2 cross-reactive protein in rodent brain stem homogenates, but not in central nervous system myelin. Key Words: Basic proteins--PNS myelin--CNS myelin--Immunocharacterization. Greenfield S. et al. Basic proteins of rodent peripheral nerve myelin: Immunochemical identification of the 21.5K, 18.5K, 17K, 14K, and P2 proteins.