Thirteen-year audit of the management of anorectal fistulae in a tertiary colorectal unit.

BACKGROUND: Persistent anorectal fistulae are referred for assessment in the Durban Metropolitan area to the colorectal unit at the tertiary hospital. This audit aimed to report the assessment and management of these fistulae to benchmark the outcomes from these approaches at a South African tertiary colorectal unit. METHODS: Retrospective analysis of prospectively collected data of patients with anorectal fistulae over a 13-year period at a tertiary referral centre. Data analysed included demographics, clinical presentation, comorbidity, management and outcome. Study outcomes measures were healing time and secondary outcome measures were complications of surgery. RESULTS: One hundred and thirty-three patients (median age 44 and M:F ratio 2.8:1) with 206 fistulae were accrued. The initial assessment and diagnostic procedures included insertion of seton (126), fistulectomy (14), and fistulotomy (65). Definitive procedures included two-stage seton fistulotomy (43), ligation of the inter-sphincteric fistula tract (LIFT) procedure (39), modified Hanley procedure (17), and mucosal advancement flap (5). One patient had no surgery and nine did not undergo a definitive procedure. Additional procedures included anal sphincter reconstruction (2) and repair of rectovaginal fistula (2). Residual anal incontinence occurred in 13.5%. The failure rate was 6% and healing occurred in 94%. The median healing time was 8 months after the initial surgery and 4 months following the definitive procedure. CONCLUSION: The fistula healing rate overall was 94% and was associated with an incontinence rate of 13.5%.

Laboratory comparison of stool processing methods for Xpert® Ultra.

TB disease diagnosis in children is difficult due to non-specific symptoms, paucibacillary disease and the need for invasive procedures to obtain diagnostic specimens. In many settings, these specimens are simply not collected and therefore stool, easily obtained, has emerged as a promising specimen for the diagnosis of child TB. In this study, stool from a healthy adult was spiked with known concentrations of bacille Calmette-Guérin vaccine and tested using the Xpert® Ultra assay to determine the relative detection and error rate associated with four different published stool processing methods.

Le diagnostic de TB maladie chez l'enfant est difficile en raison de la non spécificité de symptômes, de son caractère paucibacillaire et du besoin de procédures invasives pour obtenir des échantillons diagnostiques. Dans de nombreux contextes, ces échantillons ne sont tout simplement pas recueillis ; c'est pourquoi les selles, faciles à obtenir, sont apparus comme un échantillon prometteur pour le diagnostic de la TB de l'enfant. Dans cette étude, des selles d'un adulte en bonne santé ont été enrichies avec des concentrations connues de vaccin Bacille Calmette-Guérin et testés avec le test Xpert Ultra pour déterminer les taux relatifs de détection et d'erreur associés à quatre différentes méthodes publiées de traitement des selles.

Differential expression of miRNAs in pancreatobiliary type of periampullary adenocarcinoma and its associated stroma.

Periampullary adenocarcinomas can be of two histological subtypes, intestinal or pancreatobiliary. The latter is more frequent and aggressive, and characterized by a prominent desmoplastic stroma, which is tightly related to the biology of the cancer, including its poor response to chemotherapy. Whereas miRNAs are known to regulate various cellular processes and interactions between cells, their exact role in periampullary carcinoma remains to be characterized, especially with respect to the prominent stromal component of pancreatobiliary type cancers. The present study aimed at elucidating this role by miRNA expression profiling of the carcinomatous and stromal component in twenty periampullary adenocarcinomas of pancreatobiliary type. miRNA expression profiles were compared between carcinoma cells, stromal cells and normal tissue samples. A total of 43 miRNAs were found to be differentially expressed between carcinoma and stroma of which 11 belong to three miRNA families (miR-17, miR-15 and miR-515). The levels of expression of miRNAs miR-17, miR-20a, miR-20b, miR-223, miR-10b, miR-2964a and miR-342 were observed to be higher and miR-519e to be lower in the stromal component compared to the carcinomatous and normal components. They follow a trend where expression in stroma is highest followed by carcinoma and then normal tissue. Pathway analysis revealed that pathways regulating tumor-stroma interactions such as ECM interaction remodeling, epithelial-mesenchymal transition, focal adhesion pathway, TGF-beta, MAPK signaling, axon guidance and endocytosis were differently regulated. The miRNA-mRNA mediated interactions between carcinoma and stromal cells add new knowledge regarding tumor-stroma interactions.

Epidemiology and outcomes of carbapenem-resistant Klebsiella pneumoniae bacteriuria in kidney transplant recipients.

BACKGROUND: Little is known about the epidemiology of carbapenem-resistant Klebsiella pneumoniae (CRKP) bacteriuria following kidney transplantation. We determined the incidence of post-transplant CRKP bacteriuria in adults who underwent kidney transplant from 2007 to 2010 at 2 New York City centers. METHODS: We conducted a case-control study to identify factors associated with CRKP bacteriuria compared with carbapenem-susceptible K. pneumoniae (CSKP) bacteriuria, assessed whether CRKP bacteriuria was associated with mortality or graft failure, and compared outcomes of treated episodes of CRKP and CSKP bacteriuria. RESULTS: Of 1852 transplants, 20 (1.1%) patients developed CRKP bacteriuria. Factors associated with CRKP bacteriuria included receipt of multiple organs (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.1-20.4), deceased-donor allograft (OR 5.9, 95% CI 1.3-26.8), transplant admission length of stay (OR 1.1 per day, 95% CI 1.0-1.1), pre-transplant CRKP infection or colonization (OR 18.3, 95% CI 2.0-170.5), diabetes mellitus (OR 2.8, 95% CI 1.0-7.8), and receipt of antimicrobials other than trimethoprim-sulfamethoxazole (OR 4.3, 95% CI 1.6-11.2). CONCLUSION: Compared to CSKP bacteriuria, CRKP bacteriuria was associated with increased mortality (30% vs. 10%, P = 0.03) but not graft failure. Treated episodes of CRKP bacteriuria were less likely to achieve microbiologic clearance (83% vs. 97%; P = 0.05) and more likely to recur within 3 months (50% vs. 22%, P = 0.02) than CSKP episodes. CRKP bacteriuria after kidney transplant is associated with mortality and antimicrobial failure after treatment.

Kidneys at higher risk of discard: expanding the role of dual kidney transplantation.

Half of the recovered expanded criteria donor (ECD) kidneys are discarded in the United States. A new kidney allocation system offers kidneys at higher risk of discard, Kidney Donor Profile Index (KDPI)>85%, to a wider geographic area to promote broader sharing and expedite utilization. Dual kidney transplantation (DKT) based on the KDPI is a potential option to streamline allocation of kidneys which otherwise would have been discarded. To assess the clinical utility of the KDPI in kidneys at higher risk of discard, we analyzed the OPTN/UNOS Registry that included the deceased donor kidneys recovered between 2002 and 2012. The primary outcomes were allograft survival, patient survival and discard rate based on different KDPI categories (<80%, 80-90% and >90%). Kidneys with KDPI>90% were associated with increased odds of discard (OR=1.99, 95% CI 1.74-2.29) compared to ones with KDPI<80%. DKTs of KDPI>90% were associated with lower overall allograft failure (HR=0.74, 95% CI 0.62-0.89) and better patient survival (HR=0.79, 95% CI 0.64-0.98) compared to single ECD kidneys with KDPI>90%. Kidneys at higher risk of discard may be offered in the up-front allocation system as a DKT. Further modeling and simulation studies are required to determine a reasonable KDPI cutoff percentile.

Nonsyndromic tooth agenesis patterns and associated developmental dental anomalies: a literature review with radiographic illustrations.

Tooth agenesis is one of the most intriguing phenomena, because it is frequently associated with other oral anomalies, structural variations and malformations of other teeth, late eruption, transposition and crowding. The diagnosis can be quite challenging as radiographic examination is critical for the diagnosis but not always possible and the late developing teeth may be sometimes scored developmentally missing. Accurate diagnosis therefore requires radiographic, clinical, and dental cast examinations. It is an important clinical and public health problem. Patients with missing permanent teeth may suffer from a reduced chewing ability, inarticulate pronunciation, and an unfavorable aesthetic appearance. Clinically, early diagnosis of a dental anomaly can alert the clinician to the possible development of other associated dental anomalies in the same patient or family, and avoid the possible sequelae. Understanding of tooth agenesis patterns and their impact on diagnosis, prevention, and eventually therapeutics are becoming integral parts of comprehensive dental care. Dental examination with radiographic screening of hypodontia in early childhood should be emphasized as part of public oral health policy to allow early diagnosis and timely intervention.

Availability, utilization and outcomes of deceased diabetic donor kidneys; analysis based on the UNOS registry.

The number of kidneys obtained from deceased diabetic donors available for transplantation has increased >eightfold increase in the past 15 years. We assessed allograft outcomes associated with deceased diabetic donors and compared them with that of standard and extended criteria donors (ECD) in the UNOS data registry. We identified 1982 recipients of diabetic standard criteria donors over a 10-year period from 1995 through 2004. Both overall and death-censored survival of organs from diabetic standard criteria donors was significantly better than that of organs obtained from nondiabetic ECD while inferior to that from nondiabetic standard criteria donors. Compared with ECD donors, diabetic donors had lower serum creatinine, less cold ischemia and these kidneys were less likely to be pump-perfused. Recipients of diabetic kidneys were younger and less likely to experience delayed graft function compared with recipient of ECD kidneys. More recently, many diabetic donor kidneys have been given to diabetic recipients with early graft survival being similar to that among nondiabetic recipients. These findings demonstrate the potential to expand and to improve utilization of this resource without compromising outcomes for recipients. Improved, evidence-based evaluation and allocation of deceased diabetic donor kidneys is needed to optimize their use.

Reduced fracture risk with early corticosteroid withdrawal after kidney transplant.

Corticosteroid use after kidney transplantation results in severe bone loss and high fracture risk. Although corticosteroid withdrawal in the early posttransplant period has been associated with bone mass preservation, there are no published data regarding corticosteroid withdrawal and risk of fracture. We hypothesized lower fracture incidence in patients discharged from the hospital without than with corticosteroids after transplantation. From the United States Renal Data System (USRDS), 77, 430 patients were identified who received their first kidney transplant from 2000 to 2006. Fracture incidence leading to hospitalization was determined from 2000 to 2007; discharge immunosuppression was determined from United Networks for Organ Sharing forms. Time-to-event analyses were used to evaluate fracture risk. Median (interquartile range) follow-up was 1448 (808-2061) days. There were 2395 fractures during follow-up; fracture incidence rates were 0.008 and 0.0058 per patient-year for recipients discharged with and without corticosteroid, respectively. Corticosteroid withdrawal was associated with a 31% fracture risk reduction (HR 0.69; 95% CI 0.59-0.81). Fractures associated with hospitalization are significantly lower with regimens that withdraw corticosteroid. As this study likely underestimates overall fracture incidence, prospective studies are needed to determine differences in overall fracture risk in patients managed with and without corticosteroids after kidney transplantation.

Acid sensing ion channels and acid nociception.

Acid Sensing Ion Channels (ASICs) are a family of cation channels expressed principally in neurons and that are activated by protons. The sensitivity of ASICs to acidosis and their distribution in primary sensory neurons points to a significant role of these channels in acid nociception. However, despite the fact that the first ASIC was identified more than 10 years ago the physiological and pathophysiological role of this channel family remains poorly understood. In this paper, the available body of data (genetic, pharmacological, and other) on ASICs will be reviewed and the role of ASIC in normal nociception and other pain sensations will be discussed. Some of the recent drug discovery and development activities ongoing in our laboratory, which point to ASICs being a relevant target for pain modulation, will also be summarized.

Electrophysiological and in vivo characterization of A-317567, a novel blocker of acid sensing ion channels.

Acid Sensing Ion Channels (ASICs) are a group of sodium-selective ion channels that are activated by low extracellular pH. The role of ASIC in disease states remains unclear partly due to the lack of selective pharmacological agents. In this report, we describe the effects of A-317567, a novel non-amiloride blocker, on three distinct types of native ASIC currents evoked in acutely dissociated adult rat dorsal root ganglion (DRG) neurons. A-317567 produced concentration-dependent inhibition of all pH 4.5-evoked ASIC currents with an IC50 ranging between 2 and 30muM, depending upon the type of ASIC current activated. Unlike amiloride, A-317567 equipotently blocked the sustained phase of ASIC3-like current, a biphasic current akin to cloned ASIC3, which is predominant in DRG. When evaluated in the rat Complete Freud's Adjuvant (CFA)-induced inflammatory thermal hyperalgesia model, A-317567 was fully efficacious at a dose 10-fold lower than amiloride. A-317567 was also potent and fully efficacious when tested in the skin incision model of post-operative pain. A-317567 was entirely devoid of any diuresis or natriuresis activity and showed minimal brain penetration. In summary, A-317567 is the first reported small molecule non-amiloride blocker of ASIC that is peripherally active and is more potent than amiloride in vitro and in vivo pain models. The discovery of A-317567 will greatly help to enhance our understanding of the physiological and pathophysiological role of ASICs.

Minimal change disease in systemic lupus erythematosus.

We report the clinical and pathologic findings in 7 patients with systemic lupus erythematosus and minimal change disease. All 7 patients presented with full nephrotic syndrome including peripheral edema, nephrotic range proteinuria (mean 9.6 g/day), and hypoalbuminemia (mean 1.8 g/dl). In all cases, renal biopsy revealed diffuse foot process effacement in the absence of significant peripheral capillary wall immune deposits, findings consistent with minimal-change disease. In addition, 5 cases displayed mesangial electron-dense deposits, with or without associated mesangial proliferation, consistent with underlying lupus nephritis class II. In all cases, steroid therapy induced a rapid remission of nephrotic syndrome. Minimal change disease is an underrecognized and readily reversible form of nephrotic syndrome in systemic lupus erythematosus. Because it may occur superimposed on mild mesangial proliferative lupus nephritis, this entity may be misinterpreted as an atypical presentation of lupus nephritis class II. Proper recognition of this entity requires careful integration of the renal biopsy immunofluorescence and electron microscopic findings.

Influence of type II diabetes on arterial tone and endothelial function in murine mesenteric resistance arteries.

An arteriograph was used to assess myogenic tone, smooth muscle contractility and the influence of endothelial function on mesenteric resistance artery reactivity in insulin-resistant mice (C57BL/KsJ-db/db) and age- and gender-matched wild-type mice. Increases in transmural pressure induced myogenic tone in arteries from both control and db/db mice. At 12 and 16 weeks of age, greater tone developed in diabetic than in control mice. In control, but not in db/db mice, pretreatment of arteries with L-NAME potentiated myogenic tone. Indomethacin and SQ29548 (PGH2/TXA2 receptor antagonist) had no efffect in control, but inhibited myogenic tone in db/db mice. Endothelium-dependent vasodilation induced by acetylcholine and bradykinin, was depressed in db/db mice and potentiated by SQ29548 and LY333531 (protein kinase C(beta) inhibitor). Messenger RNA expression levels for PKC(beta) were over-expressed 2.5-fold in db/db relative to those in control mice. However, expression levels of mRNA for eNOS, PKC(alpha), and PKC(xi) were similar in the db/db and control mice. Collectively, these results suggest that the greater myogenic tone in resistance arteries from diabetic mice may be attributable, to greater amounts of one or more vasoconstricting prostanoids. Our data indicate that in diabetic mice, basal and agonist-stimulated NO releases are depressed and NO-mediated vasorelaxation in these mice may be countered by an endogenous vasoconstrictive prostanoid. This prostanoid-induced vasoconstriction is mediated by a PKC(beta)-dependent mechanism. Therefore, heightened activation of PKC(beta) and release of a vasoconstrictor prostanoid could play a role in endothelial dysfunction associated with type II diabetes.

Hepatic over-expression of peroxisome proliferator activated receptor gamma2 in the ob/ob mouse model of non-insulin dependent diabetes mellitus.

Studies of the molecular basis of insulin resistance have focused on the peroxisome proliferator activated receptor gamma (PPARgamma, gamma1 and gamma2). The aim of this study was to determine whether the insulin resistance in liver of diabetic animals is associated with abnormal expression of these receptors. PPARgamma mRNA and protein expression levels were quantified in liver of 9-week-old male ob/ob mice as a model of diabetes and compared to age- and gender-matched wild type control animals of the same genetic background. Semi-quantitative reverse transcription-polymerase chain reaction, using 18S rRNA as an internal standard, indicated that PPARgamma2 mRNA was significantly upregulated in ob/ob liver vs. that in wild type mice. Western blotting revealed greater immunoreactivity of PPARgamma2 in liver from ob/ob mice relative to that in wild type mice. An index of insulin resistance (product of serum glucose and insulin concentration) was correlated with liver PPARgamma2 mRNA expression (r = 0.776; p < 0.001). The findings that liver PPARgamma2 expression is (1) significantly elevated in the ob/ob model of diabetes and (2) positively associated with an index of insulin resistance, suggests a possible compensatory response through which type II diabetic and obese organisms strive to maintain insulin sensitivity of the liver.

Application of the combination of isotope ratio monitoring with isotope dilution mass spectrometry to the determination of glucose in serum.

Isotope ratio monitoring combined with n((13)C)/n((12)C) isotope dilution mass spectrometry (IRM/IDMS) provides results of low uncertainty of the order of 0.1% if it is applied to the analysis of simple mixtures as found in organic chemistry, even if only low (13)C spike additives to the sample are used. If the method is applied to the analysis of systems that require large-scale sample preparation prior to the measurement, such as the determination of glucose in serum, the results obtained exhibit a higher uncertainty that is comparable to that of the conventional gas chromatography/isotope dilution mass spectrometry (GC/IDMS) method. The reason for this observation is that the small contribution that the IRM/IDMS method makes to the uncertainty budget of the result is superimposed on a large contribution due to the sample preparation. It appears therefore that the IRM/IDMS method has no advantage over the conventional GC/IDMS method. However, if a series of measurements is carried out, and if a suitable experimental design is chosen, the IRM/IDMS method can provide valuable additional information. The influence of sample preparation on each individual result can be quantified as its deviation from the average value of all results of the series. From these data conclusions can be drawn for an improvement in sample preparation.

Distribution, density, and clustering of functional glutamate receptors before and after synaptogenesis in hippocampal neurons.

Postsynaptic differentiation during glutamatergic synapse formation is poorly understood. Using a novel biophysical approach, we have investigated the distribution and density of functional glutamate receptors and characterized their clustering during synaptogenesis in cultured hippocampal neurons. We found that functional alpha-amino-3-hydroxy-5-methyl-4-isoxazolpropionate (AMPA) and N-methyl-D-aspartate (NMDA) receptors are evenly distributed in the dendritic membrane before synaptogenesis with an estimated density of 3 receptors/microm(2). Following synaptogenesis, functional AMPA and NMDA receptors are clustered at synapses with a density estimated to be on the order of 10(4) receptors/microm(2), which corresponds to approximately 400 receptors/synapse. Meanwhile there is no reduction in the extrasynaptic receptor density, which indicates that the aggregation of the existing pool of receptors is not the primary mechanism of glutamate receptor clustering. Furthermore our data suggest that the ratio of AMPA to NMDA receptor density may be regulated to be close to one in all dendritic locations. We also demonstrate that synaptic AMPA and NMDA receptor clusters form with a similar time course during synaptogenesis and that functional AMPA receptors cluster independently of activity and glutamate receptor activation, including following the deletion of the NMDA receptor NR1 subunit. Thus glutamate receptor activation is not necessary for the insertion, clustering, and activation of functional AMPA receptors during synapse formation, and this process is likely controlled by an activity-independent signal.

Activity-dependent activation of presynaptic metabotropic glutamate receptors in locus coeruleus.

Synaptic activation of metabotropic glutamate receptors (mGluRs) in the locus coeruleus (LC) was investigated in adult rat brain slice preparations. Evoked excitatory postsynaptic potentials (EPSPs) resulting from stimulation of LC afferents were measured with current clamp from intracellularly recorded LC neurons. In this preparation, mGluR agonists (+/-)-1-aminocyclopentane-trans-1, 3-dicarboxylic acid (t-ACPD) and L(+)-2-amino-4-phosphonobutyric acid (L-AP4) activate distinct presynaptic mGluRs, resulting in an inhibition of EPSPs. When two stimuli were applied to afferents at intervals >200 ms, the amplitude of the second [test (T)] EPSP was identical in amplitude to the first [control(C)]. However, when a stimulation volley was delivered before T, the amplitude of the latter EPSP was consistently smaller than C. The activity-dependent depression (ADD) was dependent on the frequency and duration of the train and the interval between the train and T. ADD was potentiated in the presence of an excitatory amino acid (EAA) uptake inhibitor L-trans-pyrrolidine-2,4-dicarboxylic acid (t-PDC, 100 microM), changing the T/C ratio from 0.84 +/- 0.05 (mean +/- SE) in control to 0.69 +/- 0.04 in t-PDC (n = 9). In the presence of t-PDC, the depolarizing response of LC neurons to focally applied glutamate was also increased. Together, these results suggest that accumulation of EAA after synaptic stimulation may be responsible for ADD. To test if ADD is a result of the activation of presynaptic mGluRs, the effect of selective mGluR antagonists on ADD was assessed. In the presence of t-PDC, bath applied (S)-amino-2-methyl-4-phosphonobutanoic acid (MAP4, 500 microM), a mGluR group III antagonist, significantly reversed the decrease in T/C ratio after a train stimulation [from 0.66 +/- 0.04 to 0.81 +/- 0.02 (mean +/- SE), n = 5]. The T/C ratio in the presence of MAP4 was not different from that measured in the absence of a stimulation volley. Conversely, ethyl glutamic acid (EGLU, 500 microM), a mGluR group II antagonist, failed to alter the T/C ratio. Together, these results suggest that, in LC, group III presynaptic mGluR activation provides a feedback mechanism by which excitatory synaptic transmission can be negatively modulated during high-frequency synaptic activity. Furthermore, this study provides functional differentiation between presynaptic groups II and III mGluR in LC and suggests that the group II mGluR may be involved in functions distinct from those of group III mGluRs.

Social class, coronary risk factors and undernutrition, a double burden of diseases, in women during transition, in five Indian cities.

OBJECTIVE: To find out the association between social class and coronary risk factors in women. DESIGN AND SETTING: Cross-sectional surveys were conducted in six-twelve urban streets in each of five cities from various regions of India following a common study protocol and criteria of diagnosis. SUBJECTS AND METHODS: We randomly selected 3257 women, aged 25-64 years inclusive, from the cities of Moradabad (n=902), Trivandrum (n=760) Calcutta (n=410), Nagpur (n=405) and Bombay (n=780). Evaluation was by questionnaires validated at Moradabad. All subjects, after pooling of data, were divided into social class 1 (n=985), social class 2 (n=790), social class 3 (n=674), social class 4 (n=602) and social class 5 (n=206), based on various attributes of socioeconomic status. RESULTS: The prevalence of hypertension, diabetes mellitus, family history of coronary disease, obesity, central obesity and sedentary lifestyle were significantly associated with higher social classes and tobacco consumption was not associated with social class. Oral contraceptive intake and postmenopausal status were also more common among higher social classes, which may be due to more education and a longer lifespan among the higher social classes, respectively. Mean total cholesterol, high density lipoprotein cholesterol, systolic and diastolic blood pressure, mean body mass index and waist-hip ratio showed significant association with higher social classes. Mean age, body weight, body mass index, waist-hip ratio, systolic and diastolic blood pressure, total cholesterol and 2-h blood glucose were significantly positively correlated with social class, as assessed by Spearman's rank correlation. Higher social classes 1-3 were more common in Trivandrum and Bombay than in Moradabad. The prevalence of hypertension, diabetes mellitus and being overweight (body mass index >25 kg/m2) were also more common in Trivandrum and Bombay compared to Moradabad. Undernutrition was negatively associated with higher social classes and was more common in Moradabad and Nagpur than Trivandrum. CONCLUSIONS: Higher social classes among Indian urban women have a higher prevalence of coronary risk factors, hypertension, diabetes mellitus, being overweight, central obesity, sedentary lifestyle, family history of coronary disease, oral contraceptive intake and postmenopausal status. Mean concentrations of total and high density lipoprotein cholesterol were also significantly associated with higher social classes.