Minimally invasive surgery for Inflammatory Bowel Disease: a systematic review and meta-analysis of robotic versus laparoscopic surgical techniques.

BACKGROUND: To evaluate outcomes of robotic versus conventional laparoscopic colorectal resections in patients with inflammatory bowel disease (IBD). METHODS: Comparative studies of robotic versus laparoscopic colorectal resections in patients with IBD were included. Primary outcome was total post-operative complication rate. Secondary outcomes included operative time, conversion to open surgery, anastomotic leaks, intra-abdominal abscess formation, ileus occurrence, surgical site infection, re-operation, re-admission rate, length of hospital stay, and 30-day mortality. Combined overall effect sizes were calculated using random-effects model and the Newcastle-Ottawa Scale was used to assess risk of bias. RESULTS: Eleven non-randomised studies (n=5,566 patients) divided between those undergoing robotic (n=365) and conventional laparoscopic (n=5,201) surgery were included. Robotic platforms were associated with a significantly lower overall post-operative complication rate compared with laparoscopic surgery (P=0.03).Laparoscopic surgery was associated with a significantly shorter operative time (P=0.00001). No difference was found in conversion rates to open surgery (P=0.15), anastomotic leaks (P=0.84), abscess formation (P=0.21), paralytic ileus (P=0.06), surgical site infections (P=0.78), re-operation (P=0.26), re-admission rate (P=0.48), and 30-day mortality (P=1.00) between the groups.Length of hospital stay was shorter following a robotic sub-total colectomy compared with conventional laparoscopy (P=0.03). CONCLUSION: Outcomes in the surgical management of IBD are comparable between traditional laparoscopic techniques and robotic-assisted minimally invasive surgery demonstrating the safety and feasibility of robotic platforms. Larger studies investigating the use of robotic technology in Crohn's disease and ulcerative colitis separately may be of benefit with specific focus on important IBD-related metrics.

Retraction: Lemierre's Syndrome: A Case of Life-Threatening Infection From Family Medicine Practice.

[This retracts the article DOI: 10.7759/cureus.20684.].

Does Omentopexy Make a Difference in Laparoscopic Sleeve Gastrectomy for Obesity Treatment? A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to evaluate the comparative outcomes of laparoscopic sleeve gastrectomy with omentopexy (LSGO) versus conventional laparoscopic sleeve gastrectomy (LSG) for obesity treatment. A systematic online search was conducted using the available online databases, and Revman software was used for data analysis. Twenty-two eligible comparative studies were included (n = 9,321). LSGO showed a significantly lower rate of gastric leak (P = 0.0001), staple line bleeding (P = 0.00001), and gastric torsion (P = 0.002) in comparison to the LSG group. Operative time was significantly shorter in the LSG group (P = 0.00001); however, the length of hospital stay was in favour of the LSGO (P = 0.00001). Compared to LSG without omentopexy, LSG with omentopexy provides a significantly lower rate of postoperative complications and shorter LOS at the expense of operative time.

Comparing Thoracic Epidural Anaesthesia to Rectus Sheath Catheter Analgesia for Postoperative Pain After Major Abdominal Surgeries: A Systematic Review.

Controlling postoperative pain is essential for the greatest recovery following major abdominal surgery. Thoracic epidural analgesia (TEA) has traditionally been considered the preferred method of providing pain relief after major abdominal surgeries. Thoracic epidural analgesia has a wide range of complications, including residual motor blockade, hypotension, urine retention with the need for urinary catheterisation, tethering to infusion pumps, and occasional failure rates. In recent years, rectus sheath catheter (RSC) analgesia has been gaining popularity. The purpose of this review is to compare the effectiveness of TEA and RSC in reducing pain following major abdominal surgeries. Four randomised controlled trials (RCTs) reporting outcomes of the visual analogue scale (VAS) pain score were included according to the set criteria. A total of 351 patients undergoing major abdominal surgery were included in this meta-analysis. There were 176 patients in the TEA group and 175 patients in the RSC group. In the random effect model analysis, there was no significant difference in VAS pain score in 24 hours at rest (standardised mean difference (SMD) -0.46; 95% CI -1.21 to 0.29; z=1.20, P=0.23) and movement (SMD -0.64; 95% CI -1.69 to -0.14; z=1.19, P=0.23) between TEA and RSC. Similarly, there was no significant difference in pain score after 48 hours at rest (SMD -0.14; 95% CI -0.36 to 0.08; z=1.29, P=0.20) or movement (SMD -0.69; 95% CI -2.03 to 0.64; z=1.02, P=0.31). In conclusion, our findings show that there was no significant difference in pain score between TEA and RSC following major abdominal surgery, and we suggest that both approaches can be used effectively according to the choice and expertise available.

Appendiceal Foreign Bodies in Adults: A Systematic Review of Case Reports.

Adults can accidentally swallow foreign bodies (FBs) with food. In rare occasions, these can lodge in the appendix lumen causing inflammation. This is known as foreign body appendicitis. We conducted this study to review different types and management of appendiceal FBs. A comprehensive search on PubMed, MEDLINE, Embase, Cochrane Library and Google Scholar was performed to detect appropriate case reports for this review. Case reports eligible for this review included patients above 18 years of age with all types of FB ingestion causing appendicitis. A total of 64 case reports were deemed to be eligible for inclusion in this systematic review. The patient mean age was 44.3 ± 16.7 years (range, 18-77). Twenty-four foreign bodies were identified in the adult appendix. They were mainly lead shot pellet, fishbone, dental crown or filling, toothpick, and others. Forty-two percent of the included patients presented with classic appendicitis pain, while 17% were asymptomatic. Moreover, the appendix was perforated in 11 patients. Regarding modalities used for diagnosis, computed tomography (CT) scans confirmed the presence of FBs in 59% of cases while X-ray only managed to detect 30%. Almost all of the cases (91%) were treated surgically with appendicectomy and only six were managed conservatively. Overall, lead shot pellets were the most common foreign body found. Fishbone and toothpick accounted for most of the perforated appendix cases. This study concludes that prophylactic appendicectomy is recommended for the management of foreign bodies detected in the appendix, even if the patient is asymptomatic.

Early weight gain in infants with Robin sequence after mandibular distraction.

This retrospective cohort study was performed to assess weight gain in infants with Robin sequence (RS) treated by mandibular distraction osteogenesis (MDO). The primary outcome variable was average daily weight gain for the following time periods: (1) birth to MDO (T1), (2) MDO to distractor removal (T2), (3) distractor removal to 6 months later (T3), and (4) 6 months to 12 months following distractor removal (T4). Published growth curves were used for comparison. Differences were assessed using the Wilcoxon matched-pairs signed rank test. Twenty-two infants were included in the study. During T1, the infants had 9.47 ± 12.61 g/day less weight gain than expected (P = 0.001). However, for T2, T3, and T4, the infants demonstrated 3.48 ± 6.17 g/day (P = 0.028), 2.19 ± 4.47 g/day (P = 0.030), and 1.83 ± 3.25 g/day (P = 0.028) more weight gain than expected. Feeding tube use resulted in improved weight gain during T1 (P < 0.001), but was associated with poorer weight gain in T3 (P = 0.003) and T4 (P = 0.001). In conclusion, infants with RS treated by MDO demonstrated poorer weight gain relative to their peers between birth and the MDO operation. However, from the MDO procedure to 12 months post-distractor removal, infants who had MDO showed faster weight gain than their age-matched peers.

Lemierre's Syndrome: A Case of Life-Threatening Infection From Family Medicine Practice.

The use of antibiotic therapy has led to a major transformation in medicine with a substantial reduction in mortality. Due to the adverse effects associated with inappropriate antibiotic use, antibiotic stewardship interventions have been promoted to improve antibiotic prescription. However, delayed antibiotic therapy, when clinically needed, may result in increased morbidity. Here, we report the case of a previously healthy young man with an untreated acute upper respiratory infection for two weeks, who presented with headache and fever. Physical examination suggested meningitis as evident by neck stiffness and positive Kernig sign. Purulent tonsilitis was also noted. Laboratory findings showed leukocytosis and elevated inflammatory markers. The patient underwent a computed tomography scan to rule out space-occupying lesions prior to lumbar puncture. The scan revealed thrombophlebitis of the left internal jugular vein that extended to the dural venous sinuses. Magnetic resonance imaging confirmed the intracranial dissemination of the disease. Such findings conferred the diagnosis of Lemierre's syndrome. The patient was admitted to the intensive care unit where he received systemic anticoagulation and prolonged intravenous antibiotics. He developed a good response and was discharged with no residual deficits after six weeks of hospitalization. Lemierre's syndrome is a serious infection that develops after a pharyngeal infection. Considering the high mortality rate of untreated Lemierre's syndrome, physicians should keep a high index of suspicion for this condition when they encounter a patient with upper respiratory tract infection with clinical or radiological findings consistent with internal jugular thrombophlebitis.

Epitope-Based Peptide Vaccine against Glycoprotein G of Nipah Henipavirus Using Immunoinformatics Approaches.

BACKGROUND: Nipah belongs to the genus Henipavirus and the Paramyxoviridae family. It is an endemic most commonly found at South Asia and has first emerged in Malaysia in 1998. Bats are found to be the main reservoir for this virus, causing disease in both humans and animals. The last outbreak has occurred in May 2018 in Kerala. It is characterized by high pathogenicity and fatality rates which varies from 40% to 70% depending on the severity of the disease and on the availability of adequate healthcare facilities. Currently, there are no antiviral drugs available for NiV disease and the treatment is just supportive. Clinical presentations for this virus range from asymptomatic infection to fatal encephalitis. OBJECTIVE: This study is aimed at predicting an effective epitope-based vaccine against glycoprotein G of Nipah henipavirus, using immunoinformatics approaches. METHODS AND MATERIALS: Glycoprotein G of the Nipah virus sequence was retrieved from NCBI. Different prediction tools were used to analyze the epitopes, namely, BepiPred-2.0: Sequential B Cell Epitope Predictor for B cell and T cell MHC classes II and I. Then, the proposed peptides were docked using Autodock 4.0 software program. Results and Conclusions. The two peptides TVYHCSAVY and FLIDRINWI have showed a very strong binding affinity to MHC class I and MHC class II alleles. Furthermore, considering the conservancy, the affinity, and the population coverage, the peptide FLIDRINWIT is highly suitable to be utilized to formulate a new vaccine against glycoprotein G of Nipah henipavirus. An in vivo study for the proposed peptides is also highly recommended.

British children's performance on the listening in spatialised noise-sentences test (LISN-S).

Objective: To investigate whether British children's performance is equivalent to North American norms on the listening in spatialised noise-sentences test (LiSN-S). Design: Prospective study comparing the performance of a single British group of children to North-American norms on the LiSN-S (North American version). Study sample: The British group was composed of 46 typically developing children, aged 6-11 years 11 months, from a mainstream primary school in London. Results: No significant difference was observed between the British's group performance and the North-American norms for Low-cue, High-cue, Spatial Advantage and Total Advantage measure. The British group presented a significantly lower performance only for Talker Advantage measure (z-score: 0.35, 95% confidence interval -0.12 to -0.59). Age was significantly correlated with all unstandardised measures. Conclusion: Our results indicate that, when assessing British children, it would be appropriate to add a corrective factor of 0.35 to the z-score value obtained for the Talker Advantage in order to compare it to the North-American norms. This strategy would enable the use of LiSN-S in the UK to assess auditory stream segregation based on spatial cues.

Pattern and predictors of neurological morbidities among childhood cerebral malaria survivors in central Sudan.

BACKGROUND & OBJECTIVES: Cerebral malaria is considered a leading cause of neuro-disability in sub-Saharan Africa among children and about 25% of survivors have long-term neurological and cognitive deficits or epilepsy. Their development was reported to be associated with protracted seizures, deep and prolonged coma. The study was aimed to determine the discharge pattern and to identify potential and informative predictors of neurological sequelae at discharge, complicating childhood cerebral malaria in central Sudan. METHODS: A cross-sectional prospective study was carried out during malaria transmission seasons from 2000 to 2004 in Wad Medani, Sinnar and Singa hospitals, central Sudan. Children suspected of having cerebral malaria were examined and diagnosed by a Pediatrician for clinical, laboratory findings and any neurological complications. Univariate and multiple regression model analysis were performed to evaluate the association of clinical and laboratory findings with occurrence of neurological complications using the SPSS. RESULTS: Out of 940 examined children, only 409 were diagnosed with cerebral malaria with a mean age of 6.1 ± 3.3 yr. The mortality rate associated with the study was 14.2% (58) and 18.2% (64) of survivors (351) had neurological sequelae. Abnormal posture, either decerebration or decortication, focal convulsion and coma duration of >48 h were significant predictors for surviving from cerebral malaria with a neurological sequelae in children from central Sudan by Univariate analysis. Multiple logistic regression model fitting these variables, revealed 39.6% sensitivity for prediction of childhood cerebral malaria survivors with neurological sequelae (R² = 0.396; p=0.001). INTERPRETATION & CONCLUSION: Neurological sequelae are common due to childhood cerebral malaria in central Sudan. Their prediction at admission, clinical presentation and laboratory findings may guide clinical intervention and proper management that may decrease morbidity and improve CM consequences.

Chloral hydrate versus midazolam as sedative agents for diagnostic procedures in children.

OBJECTIVE: To compare sedation outcomes for chloral hydrate (CH) and midazolam (MD) as sedative agents for diagnostic procedures in children. METHODS: A prospective, randomized, double-blinded study conducted between July 2005 and October 2006, at the Pediatric Day Care Unit (DCU), King Abdulaziz Medical City, Riyadh, Saudi Arabia. After meeting the inclusion criteria and getting informed consent, patients were randomized, given the study drug, and monitored for sedation outcomes. RESULTS: Two hundred and seventy-five patients who had 292 sedation sessions for diagnostic procedures were included in the study. Due to missing data, 286 sedations were included in the final analysis; 144 in the CH and 142 in the MD group. Both groups were comparable with respect to demographic and baseline characteristics. The CH compared to MD group, had a higher sedation success rate, shorter time to achieve sedation, shorter length of stay in DCU, and longer sedation duration. In both study groups, patients who required a second dose tended to be older and heavier. No major side effects were encountered. The CH group had a significantly higher mean sedation scores at 15, 30, 45, and 60 minutes. CONCLUSION: Chloral hydrate compared to MD, had a shorter time to achieve sedation, a higher success rate, less need for a second dose, and decreased the time spent in the DCU. Older and heavier patients are more likely to require a second dose of the study drug to be sedated.

Barrett's esophagus suspected at endoscopy but no specialized intestinal metaplasia on biopsy, what's next?

OBJECTIVES: There are no guidelines regarding the best practice for when Barrett's esophagus (BE) is suspected but not confirmed by histology. The aim of this study was to examine the value of endoscopic follow-up for individuals with endoscopic only BE at index endoscopy. METHODS: We performed a longitudinal study of patients diagnosed with suspected columnar lined esophagus (CLE) (suspected BE in the absence of histological confirmation of specialized intestinal metaplasia (IM)). We examined three possible outcomes (definite BE defined as CLE plus IM in targeted biopsies, suspected CLE, or no suspected CLE) on repeat endoscopy within 2 years after the index endoscopy and their predictors (clinical, demographic as well as endoscopists' identity). RESULTS: A total of 107 of 1,844 patients had suspected CLE (101 were <3 cm), and 80 underwent a repeat endoscopy within 2 years. Approximately, 71% (95% confidence interval (CI) 61.1-80.9%) had suspected CLE confirmed at repeat endoscopy and only 29% (95% CI 19.1-38.9%) had IM. The length of CLE on the index esophagogastroduodenoscopies was slightly longer among patients with definite BE on repeat endoscopy than those with suspected CLE and no IM or no CLE (1.6 cm (s.d. 1.3) vs. 1.5 cm (s.d. 1.4), and 1.4 cm (s.d. 1.2), respectively P>0.1). Patient demographics, body mass index, gastro-esophageal reflux disease symptoms, hiatal hernia, and endoscopists' identity were not significantly associated with the outcome on the repeat endoscopy. CONCLUSIONS: Most (71%) patients with suspected CLE remain negative for IM in the 2 years following the index endoscopy. The findings support withholding BE diagnosis for individuals with suspected CLE.

The utility of evaluating low serum albumin gradient ascites in patients with cirrhosis.

OBJECTIVES: Serum-ascites albumin gradient (SAAG) has been used extensively in the diagnostic workup of patients with ascites. A SAAG level of <1.1 g/dl is usually thought of as a result of nonportal hypertension etiologies, including malignancies, tuberculous peritonitis, and nephrotic syndrome. However, the predictive value of a low SAAG in patients with existing cirrhosis in whom the pretest probability of portal hypertension is high is not clear. METHODS: We identified all patients with a SAAG of <1.1 g/dl during a 5-year period at a single large veterans affairs medical center. Cirrhosis was defined by clinical, histological, and radiological features. Nonportal hypertension causes of low SAAG were identified, including bacterial peritonitis, peritoneal carcinomatosis, nephrogenous ascites, tuberculous peritonitis, chylous ascites, and pancreatic ascites. RESULTS: We identified 92 patients (76 with cirrhosis and 16 with no cirrhosis) with ascites and a SAAG of <1.1 g/dl. Of the 76 patients with cirrhosis, only 29 (38%) had an identifiable cause, most commonly primary bacterial peritonitis (11, 38%), followed by peritoneal carcinomatosis or malignant ascites (8, 28%) and nephrotic syndrome (5, 17%). There were 47 patients with cirrhosis and a low SAAG for whom no etiology was identified. Thirty-three patients underwent a repeat paracentesis, 24 (73%) of whom changed to a high SAAG. On the other hand, the 16 patients with no cirrhosis had significantly lower SAAG (0.66 vs. 0.81), and most (12, 75%) had an identifiable cause of ascites. CONCLUSIONS: Evaluation of a SAAG <1.1 g/dl in patients with known cirrhosis has low yield and is less likely to be helpful than that in patients without cirrhosis. A repeat paracentesis as part of the workup is recommended. Further studies of low SAAG cutoffs are needed.

Antithrombotic properties of the thromboxane A2/prostaglandin H2 receptor antagonist S18886 on prevention of platelet-dependent cyclic flow reductions in dogs.

A potent thromboxane A2/PGH2 (TP)-receptor antagonist, S18886, was evaluated for its antithrombotic property in a dog model of acute periodic platelet-mediated thrombosis in stenosed coronary arteries with endothelial damage. After thrombosis had been obtained in 11 dogs, S18886 (300 microg/kg bolus) was administered IV. Heart rate, systemic blood pressure, and coronary blood flow were continuously recorded. Ex vivo whole blood platelet aggregation (PA), blood pH, hematocrit, platelet count, PO2, PCO2, and bleeding times were measured before and 30 minutes after administration of S18886. S18886 completely inhibited thrombosis in all dogs in approximately 5-10 minutes. No change in heart rate, blood pressure, pH, PO2, PCO2, platelet count, or bleeding time and a slight but significant elevation in hematocrit occurred. Infusion of epinephrine IV after complete inhibition of thrombosis by S18886 partially restored thrombosis in 3 of the 11 dogs. PA induced by collagen (4 microg/mL), collagen (0.25 microg/mL) plus epinephrine (1 microg/mL), collagen (1 microg/mL) plus epinephrine (1 microg/mL), ADP (40 microM) plus epinephrine (1 microg/mL), and phorbol 12-myristate 13-acetate (0.5 nM) were attenuated by 90 +/- 8% (P < 0.005), 98 +/- 2% (P < 0.05), 78 +/- 6% (P < 0.005), 70 +/- 10% (P < 0.005), and 28 +/- 8% (P < 0.05), respectively. In conclusion, S18886 is a potent platelet inhibitor that attenuates in vivo platelet-dependent thrombosis in the experimental dog model and reduces ex vivo platelet aggregation.

Grape seed and grape skin extracts elicit a greater antiplatelet effect when used in combination than when used individually in dogs and humans.

Grape products, rich in polyphenolics, inhibit platelet aggregation (PA), a risk factor for coronary artery disease. We postulated that combining extracts of grape seed (GSD) and grape skin (GSK), primary sources of grape polyphenolics, individually shown to inhibit PA, might enhance their individual antiplatelet effects. This hypothesis was examined in vitro (human platelets) and ex vivo (dog platelets) by studying the effects of the extracts on collagen-induced whole blood PA. In vitro, threshold concentration of only GSD, individually incubated with blood, significantly inhibited PA; PA was inhibited by 12.7 +/- 3.5% (P < or = 0.01). No significant changes in Pa were observed with threshold concentrations of GSK, used individually. In two dose combinations, GSD and GSK inhibited PA 40.5 +/- 10.1% (P < or = 0.005) and 96.5 +/- 3.1% (P < or = 0.001). In the ex vivo study, seven dogs were fed threshold doses of GSD or GSK individually, in combination or in combination with a proprietary enzyme blend (EB; thought to enhance bioavailability) for 8 d. PA was measured before and after each treatment. PA measurements were also repeated 24 h after the final dose of GSD + GSK + EB. Feeding the extracts individually did not affect PA, whereas feeding them in combination inhibited PA by 31.9 +/- 7.1% (P < or = 0.05). Feeding EB in addition to GSD + GSK inhibited PA by 56.2 +/- 8.1% (P < or = 0.005); 24 h later, PA was still inhibited by 31.5 +/- 10.5% (P < or = 0.05), suggesting a residual antiplatelet effect from the administration of the final dose. The results suggest that the components of GSD and GSK, when present in combination as in red wine, grape juice or in a commercial preparation containing both extracts, exhibit a greater antiplatelet effect than when present individually.

The effects of tracheal occlusion and release on type II pneumocytes in fetal lambs.

UNLABELLED: Fetal tracheal occlusion (TO) has been shown to lead to lung hyperplasia in various animal models, and this procedure has already been carried out in human fetuses with congenital diaphragmatic hernia (CDH). However, the authors previously showed that TO caused a decrease in type II pneumocytes. PURPOSE: The aim of this study is to examine the effects of TO and release on type II pneumocytes. METHOD: To was carried out with a Swan Ganz or Fogarty catheter in fetal sheep at 116 to 118 days of gestation. TO was maintained for 2 weeks followed by deflation of the balloon for 1 week before delivery, in group 1; in group 2, TO was maintained for 19 days and released 2 days before delivery. Group 3 consisted of previously reported animals who had TO maintained until birth. Unoperated twins served as controls. All specimens were analyzed using the surfactant protein C (SP-C) mRNA as a specific marker for type II pneumocytes. We used Northern Blot and in situ hybridization techniques to quantify total SP-C and the density of type II cells. Electron microscopy (EM) was also used to evaluate and quantitate type II cells. RESULTS: TO resulted in significant lung growth in all groups. In situ hybridization and Northern Blot analysis showed that there was a complete recovery of type II cells in group 1 versus controls. Quantitative EM analysis confirmed these findings. In group 2 the number of type II cells was decreased but there was an increase in SP-C content per type II cell versus group 3. CONCLUSION: Lung growth after TO appears to occur at the expense of type II cell differentiation. This effect is reversible with the release of TO before birth in this animal model.

Deleterious effect of tracheal obstruction on type II pneumocytes in fetal sheep.

It was previously shown that tracheal obstruction accelerated fetal lung growth and eventually reversed the pulmonary hypoplasia in experimental diaphragmatic hernia. We have successfully developed a reversible tracheal obstruction technique in fetal sheep using balloon occlusion and showed that 3 wk of obstruction induced significant lung growth of the same magnitude as the tracheal ligation. The purpose of this study was to examine the effects of 1 and 3 wk of tracheal occlusion on the alveolar cell population with specific attention to the type II pneumocytes. We first showed that 1 wk of occlusion induced a significant increase in lung weight and in alveolar surface area. We then used the surfactant protein C (SP-C) mRNA as a specific marker of differentiated type II pneumocytes. Total RNA was isolated from fetal sheep lung with or without tracheal occlusion, and Northern blots were hybridized with a cDNA probe specific for the sheep SP-C. The results show a dramatic decrease in SP-C mRNA expression (8.8-fold, p < 0.01). In situ hybridization showed a marked decrease in the density of cells expressing SP-C, as well as the amount of SP-C mRNA expressed by the cells. The effect was present as early as 1 wk of occlusion. The sparseness of type II pneumocytes was further confirmed by electron microscopy. We thus conclude that tracheal obstruction causes a profound decrease in the number of type II pneumocytes in the lungs. Given the crucial role of type II pneumocytes in surfactant production, we could speculate that, if tracheal occlusion is able to accelerate lung growth, the final product is probably surfactant-deficient.

Necrotizing and suppurative lymphadenitis in Leishmania major infections.

The pathology of lymph nodes and subcutaneous nodules in 6 patients with cutaneous leishmaniasis (Oriental sore) due to Leishmania major is described in this paper. In 3 patients enlarged epitrochlear lymph nodes were found to be associated with primary skin lesions in the forearm. The lymph node in one patient showed a necrotizing granulomatous reaction that simulated tuberculous lymphadenitis. Leishmania parasites were, however, found in sections of the node, and staining for mycobacteria was negative. The second patient presented with an abscess and a discharging sinus in the epitrochlear region. Parasites were found in smears of the pus and cultures for bacteria were negative. The lesion healed with antimonial therapy. In the third patient the lesion resembled cat-scratch disease and showed stellate abscesses and granulomas. Leishmania parasites were also identified in the sections. Sections of a subcutaneous nodule from the fourth patient showed a necrotizing granuloma. The lesion healed spontaneously and the patient became leishmanin-positive. In two other patients fine needle aspiration of the subcutaneous nodules showed parasites, granuloma and necrosis. We concluded that L. major disseminates from the primary cutaneous lesion via the lymphatics to the subcutaneous tissues and the regional lymph nodes. The subcutaneous nodules and lymphadenopathy may persist long after the primary lesion had healed. The primary lesion is sometimes inconspicuous. Necrotizing and suppurative lymphadenitis due to L. major have to be distinguished from other causes of necrosis and suppuration such as tuberculosis and cat-scratch disease.

Reversible tracheal obstruction in the fetal sheep: effects on tracheal fluid pressure and lung growth.

Congenital diaphragmatic hernia (CDH) continues to carry high morbidity and mortality. A number of treatment modalities including extracorporeal membrane oxygenation and in utero repair have improved the mortality rate only minimally. With this condition, there is often insufficient lung mass at birth and persistent pulmonary hypertension postnatally. Experimental fetal tracheal ligation has been shown to increase lung growth in utero and to reduce the hernial contents in CDH. The purpose of this study was to determine the effect of reversible fetal tracheal occlusion on tracheal pressure and lung development. Nine fetal sheep were divided into two groups. Group 1 had intratracheal balloons placed, and the balloons were left inflated for 21 to 28 days. Group 2 consisted of littermates that served as controls. They either had uninflated balloons placed or were left unoperated. Tracheal pressure measurements were recorded periodically, and the amniotic fluid pressure served as a reference. The animals were killed near term, and the lungs, heart, and liver were weighed and corrected for body weight. Standard morphometry was used to compare the lungs further, and the lung DNA and protein content were measured. Tracheal damage from the balloon catheter also was assessed. The tracheal pressure was 3.85 (+/- .49 SE) mm Hg in experimental animals, and it averaged -0.27 (+/- .27 SE) mm Hg in controls (P < .0001). Tracheal occlusion increased lung weight and volume by two to three times (P < .0001 and P < .0006, respectively) while heart and liver weights remained similar to those of controls.(ABSTRACT TRUNCATED AT 250 WORDS)