Gastroduodenal Artery Pseudoaneurysm Causing Obstructive Jaundice.

Background: Visceral artery aneurysms and pseudoaneurysms are uncommon phenomena with a high mortality rate in cases of rupture. These rare vascular pathologies are usually asymptomatic and are therefore generally discovered incidentally on computed tomography or magnetic resonance imaging examination. Current therapeutic options have trended toward a minimally invasive approach because of evolving endovascular treatment options, with open operations typically reserved for cases of intraabdominal hemorrhage. Case Report: We describe a case of gastroduodenal artery pseudoaneurysm manifesting as obstructive jaundice and pancreatitis because of extrahepatic compression of the common bile duct and pancreatic duct by mass effect. Open repair was ultimately required secondary to arterial anatomy that was not amenable to any endovascular treatment approach. Conclusion: While endovascular options are the preferred treatment modality for visceral artery aneurysms and pseudo-aneurysms, some cases require definitive open repair for a variety of reasons, including unsuitable anatomy.

Evidence for exposure to selenium by breeding interior snowy plovers (Charadrius nivosus) in saline systems of the Southern Great Plains.

Interior snowy plover (Charadrius nivosus) population declines and deteriorating conditions throughout the Southern Great Plains (SGP) of Texas, New Mexico, and Oklahoma may be linked to environmental contaminants. Concentrations of V, As, Cd, Pb, and Se were quantified in breeding snowy plover blood, feathers (5th primary; P5), and potential prey (tiger beetles [Cicindela circumpicta and C. togata]). Se was (a) most commonly detected relative to other quantified elements and (b) frequently quantified at levels exceeding background or toxicity thresholds. Of samples greater than instrumentation detection limits, 98% of snowy plover blood and 22% of feather samples were greater than Se toxicity thresholds of 1 ppm ww for blood and 5 ppm dw for feathers (blood quantifiable range: 0.83-15.12 ppm; feathers quantifiable range: 1.90-27.47 ppm). Almost all tiger beetle Se concentrations were below reported invertebrate thresholds of 30 ppm dw (quantifiable range: 0.54-45.84 ppm). Snowy plover blood Se concentrations were related to sex, individual body condition, and local tiger beetle Se concentrations, while plover P5 Se concentrations were related to state, sex, and presence of body molt. Tiger beetle Se concentrations were related to individual study sites in Texas. These results provide some of the first evidence of Se exposure risk for interior snowy plovers nesting in saline lake and alkali flat environments of the SGP. Future efforts should focus upon specific Se uptake pathways during breeding and nonbreeding seasons, as snowy plovers breeding in the SGP appear to be exposed to Se throughout their annual cycle.

qSR: a quantitative super-resolution analysis tool reveals the cell-cycle dependent organization of RNA Polymerase I in live human cells.

We present qSR, an analytical tool for the quantitative analysis of single molecule based super-resolution data. The software is created as an open-source platform integrating multiple algorithms for rigorous spatial and temporal characterizations of protein clusters in super-resolution data of living cells. First, we illustrate qSR using a sample live cell data of RNA Polymerase II (Pol II) as an example of highly dynamic sub-diffractive clusters. Then we utilize qSR to investigate the organization and dynamics of endogenous RNA Polymerase I (Pol I) in live human cells, throughout the cell cycle. Our analysis reveals a previously uncharacterized transient clustering of Pol I. Both stable and transient populations of Pol I clusters co-exist in individual living cells, and their relative fraction vary during cell cycle, in a manner correlating with global gene expression. Thus, qSR serves to facilitate the study of protein organization and dynamics with very high spatial and temporal resolutions directly in live cell.

The Role of Venous and Arterial Resection in Pancreatic Cancer Surgery.

Pancreatic cancer continues to carry a dismal prognosis with the majority of patients presenting at advanced stages of disease. Complete surgical resection remains essential for prolonging survival and increasing the possibility of cure. However, few patients will be resectable at diagnosis, with a significant portion presenting with borderline or locally advanced disease. The addition of vascular resection and reconstruction at the time of pancreatectomy enables expansion of the patient population able to undergo resection with curative intent and achieve tumor-free margins. This review provides an overview of the literature regarding the role of venous and arterial resection in the treatment of pancreatic cancer, with a focus on outcomes including survival, morbidity, and mortality.

Intrahepatic stones from congenital biliary dilatation.

BACKGROUND: Congenital or primary intrahepatic bile duct (IHBD) dilatation is a rare disorder with symptoms of abdominal pain and hepatomegaly that usually presents in childhood and adolescence. Recurrent cholangitis, liver abscesses, septicemia, and biliary cirrhosis may result secondary to biliary sludge and hepatolithiasis. CASE REPORT: We present a case of IHBD dilatation with hepatolithiasis cured with surgical resection and discuss the management of this disease. CONCLUSION: IHBD dilatation should be treated, as chronic biliary stasis and hepatolithiasis can lead to infection and recurrent cholangitis that can progress to cholangiocarcinoma. Treatment for IHBD dilatation usually involves multiple modalities including medical therapy, but ultimately resection of the diseased segments or lobes is required given the increased risk of malignancy.

Intracystic Biopsy and Diagnosis of Intraductal Papillary Mucinous Neoplasm via SpyGlass Pancreatoscopy.

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas carries a risk of malignancy ranging from 15%-60%, depending on certain high-risk features. Diagnostic efforts often include radiographic imaging with computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, and endoscopic ultrasound. Once IPMN has been diagnosed, the proposed indications for cyst resection are based primarily on size, main duct involvement, symptoms, and the presence of mural nodules. Diagnostic difficulty still remains, however, in patients with small lesions and with normal carcinoembryonic antigen levels, so alternative endoscopic modalities are needed. CASE REPORT: We report a case of intracystic SpyGlass Direct Visualization System (Boston Scientific) evaluation and biopsy of an IPMN in a 74-year-old male patient who presented to our surgical clinic with a history of chronic pancreatitis and significant weight loss during the last 2½ years. CONCLUSION: In difficult diagnostic cases, SpyGlass pancreatoscopy can be quite useful because the device allows direct endoscopic visualization of the pancreaticobiliary ducts. Ductal pathology, including stones, strictures, and proliferative epithelial abnormalities, can be observed and even directly biopsied. Early experience in applying this technology to pancreatic cyst evaluation has indicated improved diagnostic accuracy.

Postgastrectomy syndromes.

The first postgastrectomy syndrome was noted not long after the first gastrectomy was performed. The indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient's long-term follow-up and care. The article does not deal with the sequelae of bariatric surgery.

Small bowel adenocarcinoma: understaged and undertreated?

BACKGROUND: Primary small bowel adenocarcinoma (SBA) is a rare, chemoresistant tumor with an aggressive clinical nature. Surgery is the mainstay of therapy, but the extent of lymph node (LN) recovery necessary for optimal care of jejunoileal SBA is unknown. MATERIALS AND METHODS: The SEER database was queried to identify patients whose primary jejunoileal SBA was diagnosed between 1995 and 2005. Patients were grouped by AJCC stage and number of LNs recovered from the surgical specimen. RESULTS: Of 1444 patients with primary SBA, 93 (6.4%), 529 (36.6%), 356 (24.7%), and 466 (32.3%) were initially diagnosed with stage I, II, III, and IV disease, respectively. Five-year overall survival (OS) rate was 59.8%, 39.5%, 27.0%, and 3.2% for patients with stage I, II, III, and IV SBA, respectively. When ≥10 nodes were recovered, OS rate increased nonsignificantly in stage I (73.2% vs. 55.6%) and significantly in stage II (61.8% vs. 32.9%, P < .001) but was unchanged in stage III (27.4% vs. 27.3%, P = .13). Recovery of ≥10 nodes occurred in 26.9%, 23.6%, and 42.1% of patients with stage I, II, and III SBA, respectively. Multivariate analysis identified age, AJCC stage, site of primary tumor, recovery of ≥10 LNs, and number of positive nodes as significant for OS. CONCLUSIONS: We have found SBA staging is largely inadequate. Our results suggest recovery of ≥10 LNs ensures accurate staging. Improvement in stage II SBA OS after adequate LN may reflect a high degree of understaging in this dataset rather than a therapeutic effect of LAD.

Does specialized surgical training increase lymph node yield in colon cancer?

Most colon cancer resections do not meet the 12-lymph node minimum recommended in 2001 National Cancer Institute (NCI) panel guidelines. Previous reports suggest surgical training influences lymph node recovery. We hypothesized that recent trends show improved results for lymphadenectomy regardless of specialty. The cancer registry database at a large community hospital with an academic surgical oncology training program was queried to identify resections performed for colon cancer before (1995 to 2000) and after (2001 to 2006) NCI guideline publication. There were no changes in pathology procedures between 374 early and 411 later procedures. The later period brought increases in mean total lymph nodes (15.4 vs 10.4, P < 0.0001), total positive nodes (1.8 vs 1.2, P = 0.005), and the percentage of procedures yielding 12 or more nodes (overall: 65.9 vs 36.0%, P < 0.0001; Stage II and III disease: 73.0 vs 41.4%, P < 0.003). In addition, mean nodal yield increased (P < 0.0001) for fellowship-trained surgeons (16.7 vs 11.2) and nonfellowship-trained surgeons (14.9 vs 10.2). Single-registry data show that since 2001, most colon resections exceed minimum recommendations for lymph node recovery regardless of surgical training. The increased rate of adequate lymphadenectomy for Stage II and III disease is encouraging because this patient population will benefit most by accurate staging of colon cancer.

Age-related lymphatic dysfunction in melanoma patients.

BACKGROUND: Age-related outcomes have become increasingly common in evaluating patients with melanoma. For instance, as age increases, sentinel node (SN) nonidentification increases and SN positivity decreases. Furthermore, advanced age is a risk factor for in-transit disease. We hypothesized that increasing age is accompanied by alterations in lymphatic function, possibly explaining these findings. METHODS: Our center's melanoma database was queried to identify patients who underwent successful sentinel node biopsy after lymphoscintigraphy. Records of those treated between 2000 and 2005 were reviewed for age, sex, drainage basin, intraoperative radioactivity, and SN pathology. RESULTS: The 858 patients had a mean age of 55 years; 59% were men. Mean radioactivity in the hottest SN was 5232 counts per second; 179 patients (21%) had SN metastases. SN count rates were significantly and inversely related to age (P < .001 by Pearson correlation, analysis of variance, and chi(2) test). Mean counts per second were 6105, 5883, and 2720 for axillary, inguinal, and cervical basins, respectively (P < .01), and count rates in these basins were consistently lower with increasing age (neck and axilla, P < .001; groin, P = .060; Pearson correlation). Multivariate analysis confirmed an independent inverse association between age and count rates (P < .001), overall and within each primary tumor site. CONCLUSIONS: Lymphatic function, as assessed by radiocolloid transit to and uptake within the SN, declines with age. Altered lymphatic function in older patients may modify metastatic patterns; knowledge of this may help clarify findings of reduced nodal positivity and increased in-transit disease in this population.

Upper GI foreign body: an adult urban emergency hospital experience.

BACKGROUND: The efficacy of flexible endoscopy by a single endoscopist in the therapy of foreign body ingestion was assessed at an adult urban emergency hospital. METHODS: Fifty-one adult patients with upper GI foreign body ingestion treated at Detroit Receiving Hospital from 1988 to 2004 were identified. Endoscopic and hospital medical records were reviewed to evaluate etiology, treatment, and outcomes for these patients. RESULTS: The etiology was related to eating in 38(75%) patients, most of whom were eating meat; phytobezoars were seen in four, often after previous upper GI surgery. True foreign bodies were found in 13 patients (25%) and included a screwdriver, a ballpoint pen, spoons, coat hanger pieces, batteries, and latex gloves. Dysphagia was the most common symptom (75%); pain was common in patients with true foreign bodies, and 62% of this group had psychiatric difficulties or problems with drug abuse. Nearly 80% of the food-related group had post-surgical or other upper GI pathology. One patient had an esophageal stricture secondary to previous Sengstaken-Blakemore tube insertion. Flexible endoscopy was successful in extracting the foreign body in almost all (49) patients, with snare extraction the most common therapeutic modality. Both failures were of true foreign bodies that could not be safely removed. In one of these cases, it became necessary to employ the gallstone lithotripter, and the overtube was required in patients with metallic or sharp foreign bodies to protect the upper aerodigestive structures. CONCLUSIONS: Most upper GI foreign bodies are related to food impaction, with meat most often found. Underlying pathology is the rule and should be dealt with immediately. Flexible endoscopy is the treatment of choice for upper GI foreign body removal with near perfect success.

Extracellular pressure stimulates tumor cell adhesion in vitro by paxillin activation.

Metastasizing colon cancer cells bind target tissues primarily via integrins. Extracellular pressure or shear stress stimulates integrin-mediated adhesion to matrix proteins or endothelial cells by activating the focal adhesion proteins FAK and Src. Because this effect is blocked by cytoskeletal perturbation and paxillin may link the cytoskeleton to the focal adhesion complex, we evaluated the role of paxillin in pressure-induced malignant colonocyte adhesion. We studied SW620 colon cancer cells and confirmed key results in Caco-2 colon cancer cells, primary human colon cancer cells, and a murine colonic adenocarcinoma. We evaluated adhesion to collagen at ambient and 15 mmHg increased pressure after 30 minutes, and paxillin, FAK, and Src phosphorylation in suspended cells prior to adhesion. Some cells were treated with siRNA to paxillin or FAK, or the Src inhibitor PP2. We also compared pressure-induced signals in suspended cells with adhesion-induced signals after adhesion to collagen. Pressure stimulated adhesion and paxillin phosphorylation in SW620 and Caco-2 cells and human primary colon cancer cells. Pressure also increased paxillin phosphorylation in murine carcinoma cells. SiRNA to paxillin decreased SW620 and Caco-2 paxillin without altering basal levels of phosphorylated paxillin. Paxillin reduction decreased basal adhesion to collagen, and inhibited pressure-stimulated adhesion, as well as paxillin, FAK397, FAK576, and Src476 phosphorylation. Neither PP2 nor siRNA to FAK inhibited induction of paxillin phosphorylation by pressure. In contrast, adhesion stimulated FAK, Src, and paxillin phosphorylation regardless of paxillin reduction. In summary, pressure induced paxillin phosphorylation in colon cancer cells. Paxillin reduction inhibited basal adhesion and blocked the pressure-mediated increase in adhesion, as well as pressure-induced FAK and Src signals, while adhesion-induced signals were preserved. Paxillin may be an upstream mediator of pressure-stimulated adhesion, important in metastasis.

Local modulation of host pH by Colletotrichum species as a mechanism to increase virulence.

The phytopathogenic fungus Colletotrichum gloeosporioides produces one pectate lyase (PL) that is a key virulence factor in disease development. During growth of C. gloeosporioides, Colletotrichum acutatum, and Colletotrichum coccodes in acidified yeast extract medium, the fungus secreted ammonia and increased the medium pH. Ammonia accumulation and the consequent pH change increased as a function of initial pH and buffer capacity of the medium. PL secretion by C. gloeosporioides correspondingly increased as the pH of the medium increased. The C. gloeosporioides pelB gene-disrupted mutant was able to increase ammonia accumulation and pH of the media similarly to the wild-type isolate. C. gloeosporioides in avocado, C. coccodes in tomato, and C. acutatum in apple showed ammonia accumulation in the infected area where pH increased to 7.5 to 8 and PL activity is optima. In nonhost interactions where C. gloeosporioides was inoculated in apples, the addition of ammonia-releasing compounds significantly enhanced pathogenicity to levels similar to those caused by the compatible C. acutatum-apple interaction. The results therefore suggest the importance of ammonia secretion as a virulence factor, enhancing environmental pH and pathogenicity of the Colletotrichum species.

Osmotic dehydration of apple slices using a sucrose/CaCl2 combination to control spoilage caused by Botrytis cinerea, Colletotrichum acutatum, and Penicillium expansum.

The efficacy of sucrose combined with CaCl2 during osmotic dehydration (OD) was tested for the control of Botrytis cinerea, Colletotrichum acutatum, and Penicillium expansum growth on lightly processed apple slices. The objective of this work was to determine whether the addition of CaCl2 in the osmotic solutions would limit the proliferation of fungal decay organisms. Slices were submitted to OD for 1 h at 25 degrees C in solutions containing 5 to 65% sucrose. Calcium chloride was added to a similar set of sucrose solutions at 0 to 8%. Control slices were made of untreated slices, and slices were processed in water. The mass ratio of the slices did not vary when fruit pieces were processed in solutions containing 5 to 65% sucrose. These slices showed a high susceptibility to spoilage compared to the control slices not submitted to OD: a significant twofold and 60% increase in decay area caused by B. cinerea and P. expansum, respectively, was observed when slices were processed in 50% sucrose/0% CaCl2; C. acutatum showed a significant 50% increase in decay area when slices were processed in 20% sucrose/0% CaCl2. Calcium uptake was significantly increased when slices were processed in CaCl2 solutions, and the highest Ca content was observed when processed in 8% CaCl2, reaching 40 times that of the control slices processed in water. Calcium-treated slices were less susceptible to spoilage by all three pathogens, and the most effective combination in reducing apple slice spoilage was 20 to 30% sucrose combined with 2% CaCl2.

Examination of bacteriophage as a biocontrol method for salmonella on fresh-cut fruit: a model study.

The preparation and distribution of fresh-cut produce is a rapidly developing industry that provides the consumer with convenient and nutritious food. However, fresh-cut fruits and vegetables may represent an increased food safety concern because of the absence or damage of peel and rind, which normally help reduce colonization of uncut produce with pathogenic bacteria. In this study, we found that Salmonella Enteritidis populations can (i) survive on fresh-cut melons and apples stored at 5 degrees C, (ii) increase up to 2 log units on fresh-cut fruits stored at 10 degrees C, and (iii) increase up to 5 log units at 20 degrees C during a storage period of 168 h. In addition, we examined the effect of lytic, Salmonella-specific phages on reducing Salmonella numbers in experimentally contaminated fresh-cut melons and apples stored at various temperatures. We found that the phage mixture reduced Salmonella populations by approximately 3.5 logs on honeydew melon slices stored at 5 and 10 degrees C and by approximately 2.5 logs on slices stored at 20 degrees C, which is greater than the maximal amount achieved using chemical sanitizers. However, the phages did not significantly reduce Salmonella populations on the apple slices at any of the three temperatures. The titer of the phage preparation remained relatively stable on melon slices, whereas on apple slices the titer decreased to nondetectable levels in 48 h at all temperatures tested. Inactivation of phages, possibly by the acidic pH of apple slices (pH 4.2 versus pH 5.8 for melon slices), may have contributed to their inability to reduce Salmonella contamination in the apple slices. Higher phage concentrations and/or the use of low-pH-tolerant phage mutants may be required to increase the efficacy of the phage treatment in reducing Salmonella contamination of fresh-cut produce with a low pH.

Variability of Three Isolates of Botrytis cinerea Affects the Inhibitory Effects of Calcium on this Fungus.

ABSTRACT Botrytis cinerea is an economically important pathogen. Epidemiological studies are difficult because of the genetic variability within this species. The objectives of this work were to study the variability and to compare the inhibitory effects of Ca on three isolates of B. cinerea from decayed apple (B) and grape (C and C77:4). Among these isolates, B had the least radial growth but had a sporulation rate 40% higher than that of both C77:4 and C. In situ, isolate C incited the largest decay area in the fruit of two of four apple cultivars examined and had the highest polygalacturonase activity in vitro. Maximum mycelial growth was reached with CaCl(2) at 1 g liter(-1) for isolates B and C77:4 and at 4 g liter(-1) for isolate C. Calcium (CaCl(2)) inhibited polygalacturonase activity at 1 g liter(-1) for C and C77:4 and at 16 g liter(-1) for B. Calcium infiltration reduced decay caused by all three isolates by three to five times. Mycelial DNA analysis showed that 42% of the character loci scored were polymorphic and the greatest similarities were found between B and C77:4. These results support the evidence that the biological and statistical variability in research can be affected by the B. cinerea isolate selected. Despite this variation, Ca treatment of apples reduced decay caused by all three Botrytis cinerea isolates.