Retromuscular mesh and hernial sac technique in the reconstruction of 139 cases of large median incisional hernias: one institution's experience.

PURPOSE: Incisional hernia is the most common complication of laparotomy. Postoperative parietal defects tend to relapse, even after the most optimal surgical methods. The aim of this study was to present the effectiveness of an adapted retromuscular technique with prolene mesh and a hernial sac, in patients with large incisional median hernias. The reported results were obtained by our team after more than 15 years of experience. METHODS: This retrospective study included 139 consecutive cases of large median incisional hernias operated on using a retromuscular mesh and hernial sac technique. The cross-sectional diameter of incisional hernias was larger than 10 cm, being classified in the W3 group, according to the European Hernia Society classification. RESULTS: The study included 83 females (59.71%) and 56 males (40.29%) with a median age of 62.4 ± 16.6 years and an average body mass index of 32.4 ± 7.6 kg. The hernia was supraumbilically located in 54 cases, subumbilically in 61 cases, and supra- and subumbilically in 24 cases. Postoperative complications were recorded in eight cases (5.75%): one case with a hematoma in the right abdominal muscle sheath; five cases with supra-aponeurotic seromas; two cases with skin necrosis and one with a mesh infection. Recurrence occurred in seven cases (5.03%): four cases in the first 2 years postoperatively and three cases in the third year after surgery. CONCLUSIONS: The retromuscular technique with prolene mesh and a hernial sac is an effective method of restoring the integrity of the abdominal wall in large median incisional hernias with low rates of morbidity and recurrence.

Stellar and primordial nucleosynthesis of 7Be: measurement of 3He(alpha,gamma)7Be.

The 3He(alpha,gamma)7Be reaction presently represents the largest nuclear uncertainty in the predicted solar neutrino flux and has important implications on the big bang nucleosynthesis, i.e., the production of primordial 7Li. We present here the results of an experiment using the recoil separator ERNA (European Recoil separator for Nuclear Astrophysics) to detect directly the 7Be ejectiles. In addition, off-beam activation and coincidence gamma-ray measurements were performed at selected energies. At energies above 1 MeV a large discrepancy compared to previous results is observed both in the absolute value and in the energy dependence of the cross section. Based on the available data and models, a robust estimate of the cross section at the astrophysical relevant energies is proposed.

Suppression of the Coulomb interaction in the off-energy-shell p - p scattering from the p + d --> p + p + n reaction.

Off-energy-shell effects in p - p scattering have been investigated at p - p relative energies from 600 down to 80 keV applying the Trojan horse method (THM) to the p + d --> p + p + n reaction at 5 MeV. In contrast with the on-energy-shell case, no Coulomb-nuclear interference minimum has been found in the extracted THM p - p cross section, due to the suppression of the Coulomb amplitude as predicted by the half-off-energy shell calculations. This hypothesis is strengthened by the agreement between THM p - p data and calculated on-energy-shell n + n, n + p and nuclear p + p cross sections.

Relationship between the mutational status of VH genes and pathogenesis of diffuse large B-cell lymphoma in Richter's syndrome.

Patients with chronic lymphocytic leukemia (CLL) may develop diffuse large B-cell lymphoma (DLBL), also known as Richter's syndrome. Mutational status of immunoglobulin (Ig) heavy-chain variable region (VH) genes have prognostic impact in CLL. Patients with mutated VH genes have a stable disease, whereas patients with unmutated VH gene have more aggressive disease. The mutational status of CLLs that transform to DLBL is unknown. To reveal whether Richter's syndrome occurs in CLLs with mutated or unmutated VH genes, we have performed mutational analysis on serial specimens from eight patients. CLL and DLBL tumorclones were identical in five cases and they were different in three cases. Six CLLs expressed unmutated and two cases expressed mutated VH genes. In five of the six unmutated CLLs, the DLBL clones evolved from CLL tumorclones and the VH genes expressed by DLBLs were also unmutated. In one unmutated and two mutated CLLs, the DLBLs expressed mutated VH genes, but in these three cases the DLBL tumorclones developed as independent secondary neoplasm. These results suggest that Richter's syndrome may develop in both mutated or unmutated CLLs, but clonal transformation of CLL to DLBL occur only in the unmutated subgroup of CLL.

Microsatellite instability and hMLH1 promoter hypermethylation in Richter's transformation of chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is an indolent B cell non-Hodgkin lymphoma (NHL) that may transform into diffuse large B cell lymphoma (DLBL). This transformation is referred to as Richter's syndrome or transformation. To analyze whether microsatellite instability (MSI) and DNA mismatch repair defects are associated with Richter's transformation, we have performed microsatellite analysis, mutational analysis of hMLH1 and hMSH2 genes and methylation status analysis of CpG island of the hMLH1 promoter on serial biopsy specimens from 19 patients with CLL. Ten cases of CLL showed no histologic alteration in the second biopsy, and nine cases of CLL underwent morphologic transformation to DLBL in the second biopsy. Using eight microsatellite loci, high level of MSI was associated with Richter's transformation in four cases of CLL, but none of the CLLs displayed this level of MSI without transformation. Mutations of the hMLH1 or hMSH2 genes were not detected in any of the lymphoma samples. In five cases of Richter's transformation the hMLH1 promoter was hypermethylated in both CLL and DLBL samples. Hypermethylation of the hMLH1 promoter associated with high-level of MSI in four cases, and low-level of MSI in one case. These results suggest that in certain cases of Richter's transformation the DNA mismatch-repair defect-initiated genetic instability may play a role in tumor progression.

Branching-pattern analysis of the dendritic arborization in the thalamic nuclei of the rat brain.

We investigated the dendritic patterns of rapid Golgi-impregnated, highly similar multipolar neurons from two functionally different thalamic regions of the rat brain: two dorsal nuclei (the nucleus laterodorsalis thalami, pars dorsomedialis and the nucleus laterodorsalis thalami, pars ventrolateralis), and two ventral nuclei (the nucleus ventrolateralis thalami and the nucleus ventromedialis thalami). The analysis involved conventional morphometric parameters (height and size) and a new parameter derived from graph theory, the relative imbalance (RI), derived from the branching patterns of the dendrites, which permits quantitative characterization of the dendritic arborization of a neuron. On this basis, neurons can be grouped into three fundamentally different types: type A, or highly-polarized (imbalanced) neurons (RI values close to 1); type B, or medium-polarized neurons (RI values around 0.5); and type C, or balanced neurons with low polarization (RI values close to 0). The orientations of the dendritic arbor, and thus the receptive fields, of the dorsal and ventral thalamic neurons, were mutually perpendicular. The H and S values indicated that the neurons in the dorsal and ventral thalamic nuclei differed significantly. However, their RI values demonstrated that they were similar neurons of type B. Our data reveal that 1 ) the dendritic arbor cannot be reliably characterized purely on the basis of height and size, and 2) RI is a valuable morphometric parameter that identifies the true nature of the dendritic arborization.

Behavioral and morphological consequences of primary astrocytes transplanted into the rat cortex immediately after nucleus basalis ibotenic lesion.

Adult male rats received transplants of dissociated 30-day old cultured cortical astrocytes into the ipsilateral frontal and parietal cortex immediately after unilateral ibotenic acid lesion of the NBM or after sham injury. We hypothesized that transplants of astrocytes into the acetylcholine-deprived cortex might provide trophic support to terminals arising from damaged NBM neurons. Twenty four hours after transplantation and every other day for 11 days post surgery, the animals were tested for locomotion and habituation in an open field. NBM lesion reduced vertical movements only as compared to no lesion and no transplant counterparts. Nine days after surgery rats with NBM lesion and astrocyte-transplants into the cortex were as impaired in the acquisition of a passive avoidance (PA) task as untreated counterparts. Animals with no lesions and transplants into the cortex also had significant PA acquisition deficits. All rats with ibotenic lesion were significantly impaired on PA retention as compared to rats with no lesions. Astrocyte-transplants survived up to 2 months after cortical implantation but these transplants produced severe laminar disruption and gliosis. This effect was greater in rats with NBM lesion than in intact animals with transplants into the cortex. These data show that astrocyte-transplants do not promote functional recovery after NBM lesion and suggest an immune rejection of the astrocyte transplants by the host brain.

Effects of the novel NMDA receptor antagonist gacyclidine on recovery from medial frontal cortex contusion injury in rats.

Gacyclidine, a novel, noncompetitive NMDA receptor antagonist, was injected (i.v.) into rats at three different doses to determine if the drug could promote behavioral recovery and reduce the behavioral and anatomical impairments that occur after bilateral contusions of the medial frontal cortex (MFC). In the Morris water maze, contused rats treated with gacyclidine at a dosage of 0.1 mg/kg performed better than their vehicle-treated conspecifics. Rats given gacyclidine at either 0.3 or 0.03 mg/kg performed better than brain-injured controls, but not as well as those treated with 0.1 mg/kg. Counts of surviving neurons in the nucleus basalis magnocellularis (NBM) and the medial dorsal nucleus (MDN) of the thalamus were used to determine whether gacyclidine treatment attenuated secondary cell death. In both the NBM and the MDN, the counts revealed fewer surviving neurons in untreated contused rats than in gacyclidine-treated rats. Increases in the size and number of microglia and astrocytes were observed in the striatum of gacyclidine-treated contused brains. Although most consequences of MFC contusions were attenuated, we still observed increases in ventricle dilation and thinning of the cortex. In fact, the ventricles of rats treated with 0.1 mg/kg of gacyclidine were larger than those of their vehicle treated counterparts, although we observed no behavioral impairment.

The effect of Ginkgo biloba extract (EGb 761) on gliotic reactions in the hippocampal formation after unilateral entorhinal cortex lesions.

PURPOSE: Ginkgo biloba extract (EGb 761) has been shown to facilitate behavioral and neuro-morphological recovery from brain injury, but less is known about its effects on glia. Since gliosis may be an important component of the recovery process, we tested the hypothesis that EGb 761 alters the time course and development of microglial activation and astrocytosis after brain injury. METHODS: Rats were treated with either saline or EGb 761 and killed at 2 hrs, 1, 3, 7, and 14 days following unilateral entorhinal cortex (EC) lesions. Microglia and their precursors were visualized with a silver impregnation method, and astrocytes with GFAP. RESULTS: Blood-borne monocytes/macrophages were seen as early as 2 hrs after injury in all animals. The side contralateral to the injury showed minimal microglial activation and there were no significant effects of drug treatment. On the side ipsilateral to the lesion EGb 761 enhanced microglial activation at 3, 7, and 14 days in the molecular layer and the hilus of the dentate gyrus; the areas of most profound deaf-ferentation after EC injury. Regions of the corpus callosum also showed enhanced microglial activation over the same time course. Reactive astrocytes were stained with GFAP and were found to be more numerous than activated microglia, particularly in the ipsilateral corpus callo-sum. EGb 761 treatment enhanced astrocytosis at 3 days in the molecular layer, the hilus, and the corpus callosum on the ipsilateral side. CONCLUSIONS: Taken together our results show that EGb 761 enhances, accelerates and prolongs the activation of microglia and astrocytosis at the site of injury.

Regional changes in the expression of neurotrophic factors and their receptors following acute traumatic brain injury in the adult rat brain.

We have analyzed the effect of severe traumatic brain injury (TBI) on the levels of mRNA expression of neurotrophic factors (NTFs): brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), ciliary neurotrophic factor (CNTF) and their respective receptors: trkB, trkA and CNTFRalpha. The expression was examined in the region of the lesion as well as a region remote from the lesion at 12, 24, and 36 h following the injury. Our data suggest that after the brain injury, the expression of NGF and BDNF mRNAs were early, transiently and significantly upregulated while that of CNTF was a slow and less amplified response in both areas of the brain. We also found that trkA mRNA expression was only upregulated significantly in the remote area; trkB mRNA showed no significant change in either area except an upregulation at 12 h in the remote area. CNTFRalpha was downregulated significantly by 24-36 h in the lesion area and by 24 h in the remote area. These changes suggest that TBI regulates the expression of NTFs and their receptors. These alterations in expression may be involved in modulating the neuronal response after brain injury.

Fluorescein-ERG, a sensitive method for the detection of vascular damage in diabetic patients.

The purpose of this paper was to provide evidence for the reintroduction of simultaneously performed fluorescein angiography and electroretinography in the detection of diabetic retinopathy. ERG observations were made in conjunction with fluorescein angiography of 13 patients suffering from type I diabetes mellitus for five to 13 years. Only patients without any fluorescein leakage during angiography and without any morphologic changes in the fundus were involved in the study. Gold foil electrodes were used for recording. A stroboscopic lamp provided flashing light stimulation through a monochromatic blue filter. Intravenous fluorescein administration caused an immediate reduction in the ERG response. This reduction was seen both in the control subjects and in diabetes patients. In the control group, the reduction was over in 30-45 min, while in the diabetes group a considerable amplitude elevation was seen in all recordings between 15 and 60 min post-fluorescein. In the adaptation control group, where only repeated ERG recordings were employed every 15 min, a slight decrease in the a wave and a slight elevation of the b wave were observed during the whole recording period. No complaints or side-effects were detected during the observations. As all the patients displayed a normal fluorescein angiography besides elevated b wave after fluorescein administration, and this elevation was seen exclusively in the diabetic group, our study raises the possibility that this diagnostic method can be used in the detection of diabetic retinopathy.

Acute ethanol administration reduces the cognitive deficits associated with traumatic brain injury in rats.

The present study was designed to determine whether a low dose of acute ethanol administration could attenuate cognitive deficits associated with traumatic brain injury. Adult male rats received oral administration of ethanol or drinking water 2 h prior to surgery to produce a blood ethanol concentration of 100 mg% and then received bilateral contusion injuries of the medial prefrontal cortex. Seven days after surgery, the rats began 10 days of testing for acquisition of spatial localization in the Morris water maze where they were required to find a hidden platform to escape from the water. The results indicate that the rats given ethanol at the time of injury later spent significantly less time searching for the hidden platform than their water-treated counterparts. On a memory probe test given on the final day of testing, in which the platform was removed from the pool, rats given the ethanol spent more time in the area where the platform had been located indicating that they learned its location better than the lesion/water controls. In addition, acute ethanol treatment reduced some of the histopathology that typically occurs following severe contusion of the medial frontal cortex but did not attenuate post-traumatic formation of edema. These results indicate that acute ethanol intoxication can reduce the severity of cognitive impairments caused by contusive traumatic brain injury and support the contention that there is a dose-response relationship of acute ethanol intoxication in the setting of traumatic brain injury.

Intraseptal injections of 192 IgG saporin produce deficits for strategy selection in spatial-memory tasks.

The involvement of the cholinergic septohippocampal system in strategies used to reach a spatial goal was examined by functionally inactivating this system with infusions of 192 IgG saporin, a potent cholinergic immunotoxin. Rats were initially trained on a win-shift radial arm maze (RAM) task and then given injections of either 192 IgG saporin (LES) or saline vehicle (CON) into the medial septum and vertical limb of the diagonal band. Rats were then retested postoperatively on the RAM to assess whether allocentric spatial strategies used to solve the task were impaired. The results indicated that injections of 192 IgG saporin into the septum of rats produced deficits in allocentric strategies used to locate the spatial goal when retested. In addition, place and response learning was also examined in a modified version of the Morris water maze task. In this task, rats with cholinergic lesions were mildly impaired in their ability to learn a place response. In order to clarify further whether rats may have been relying on allocentric or egocentric learning strategies to locate the platform, a probe trial was given on the final test day in which the visible platform was moved to a new location. Control rats swam either to the new platform location or the old platform location indicating the use of both an allocentric and egocentric response. However, rats with the cholinergic septal lesions swam to the new platform location indicating an egocentric response. Taken together, these results suggest that selective cholinergic lesions of the septum produce deficits in spatial strategies used to locate a spatial goal.

Astrocytes grafted into rat nucleus basalis magnocellularis immediately after ibotenic acid injection fail to survive and have no effect on functional recovery.

In order to determine if the "trophic" properties of astrocytes makes them appropriate for use as a therapeutic agent to excitotoxic brain damage, adult male rats received grafts of cultured cerebral cortical astrocytes into the NBM immediately after infusion of ibotenic acid into the same structure. Twenty four hours after grafting and every other day for 11 days post surgery, the animals were tested for locomotor activity and habituation in an open field. Animals with NBM lesions had significantly reduced rearing activity as compared to counterparts with no lesions. Nine days after surgery, rats with NBM lesions and astrocyte grafts were as impaired in the acquisition of passive avoidance (PA) as their untreated counterparts. All animals with ibotenic lesions were impaired on PA retention compared to rats with no lesions. There was no difference between animals that had received grafts and those that had not. Fourteen days after grafting, all brains were processed for Nissl stain, acetylcholinesterase (AChE) histochemistry, GFAP immunocytochemistry, and bisbenzamide fluorescent microscopy. Decreases in the number of neurons in the NBM as well as decreases in the density of AChE staining in the ipsilateral cortex (the area of innervation of the NBM cholinergic neurons) was evident in all animals with NBM lesions. In addition, a large number of host reactive astrocytes were seen within the NBM, its vicinity, and in the ipsilateral neocortex. Grafted astrocytes survived and integrated into the host tissue when they were grafted into the brain of intact animals but no living grafted astrocytes were found in animals injected with ibotenate. In this latter case, two weeks after grafting, instead of surviving astrocytes only fluorescent tissue 'masses' were seen in the NBM, surrounded by a cavity. Grafted astrocytes did not have any effect on the extension of the lesion caused by ibotenic acid infusion. These results suggest that the concentration of ibotenic acid used to injure the NBM killed not only the host cholinergic neurons but also the grafted astrocytes. The failure of astrocytes to ameliorate the behavioral deficits caused by ibotenic acid lesions of the NBM may be due to the ibotenic acid creating a lethal environment for the grafted and freshly dissociated, cultured astrocytes.

Synaptic remodeling and free radical formation after brain contusion injury in the rat.

The purpose of this study was to explore whether bilateral frontal cortex contusion in rats would demonstrate changes relevant for understanding the pathology of frontal lobe injury in humans. Rats were allowed to survive for 3, 7, or 18 days postinjury (dpi). In the contused rats, albumin was trapped in frontal cortices, as well as in other brain areas, showing that neurons were exposed to plasma components. In the sham-operated rats, which had only craniotomy but no penetration of dura, the level of trapped albumin was also increased compared to intact controls, suggesting a partial lesion-like condition. Choline acetyltransferase activity was severely decreased in the frontal cortices of contused rats, compared to the sham-operated controls. The decrease was most pronounced at 3 dpi and less pronounced 18 dpi, suggesting that after the initial damage, regeneration of the cholinergic terminals occurred. The concentration of the mature presynaptic membrane protein D3(SNAP-25) was also decreased in the frontal cortices of contused rats at 3 and 7 dpi, whereas it was normalized at 18 dpi. Previously, we have evaluated changes in the rate of synaptic remodeling in brain injury by calculating the ratio of the neural cell adhesion molecule (NCAM) to D3(SNAP-25). The NCAM/D3(SNAP-25) ratio at 3 dpi was elevated by more than 60% in the frontal cortices of contused rats, suggesting a high initial rate of synaptic remodeling. The ratios were smaller at 7 and 18 dpi, suggesting that after the initial burst, the rate of remodeling leveled off. In contrast, astrocyte activation was less pronounced at 3 dpi than at 7 and 18 dpi, as measured by the levels of glial fibrillary acidic protein and glutamine synthetase immunoactivities. The immunoreactivity of glutamine synthetase more than doubled in the contused brains but its enzymatic activity increased less than 50%, suggesting that many enzymatic centers had been inactivated by free radicals. Calculated as the difference between the relative immunoreactivity and the relative enzymatic activity the "lost glutamine synthetase activity" increased continuously in frontal cortex and striatum from 3 to 18 dpi, indicating the production of free radicals long after the initial contusion event. In conclusion, following frontal cortical contusions the early synaptic damage was partly compensated by synaptic remodeling. We suggest that the continuous production of free radicals may have contributed to the declining remodeling rate and impair functional recovery.

Mature but not fetal or neonatal rat superior cervical ganglion transplants survive in the cortex of adult rats.

The transplantation of catecholaminergic tissues is a possible therapy for parkinsonism. Central nervous tissue is suitable for transplantation only in the immature stage, whereas peripheral nervous tissue can also be transplanted when mature. The present study compares the development of fetal (17-20 embryonic day, E17-20), neonatal (1-3 postnatal day, P1-3) and mature (5-6-week-old) rat superior cervical ganglia after transplantation into the cerebral cortex of adult rats. The mature transplants survived in greater proportion and preserved their structural characteristics, although a considerable proportion of the neurons died. The perinatal transplants only survived sporadically, decreased in size and the surviving remnants failed to display a structure comparable to the adult ganglion in situ. Thus, the use of adult donors is not only a possibility but a necessity when superior cervical ganglion (probably any ganglion) is transplanted. This principle is radically different from that seen in the case of central nervous tissues, and can be understood by the analysis of the time curves of cell proliferation and programmed cell death (apoptosis) observed during the perinatal development of sympathetic ganglia.

Infusion of glial maturation factor-beta reduces behavioral deficits after caudate nucleus injury in rats.

Adult rats with bilateral thermal lesions of the caudate nuclei (CN) show severe learning and memory deficits. The present study was designed to test the effects of an astroglial stimulating growth factor in this behavioral model. Immediately after receiving lesions of the CN, experimental subjects received an injection of one of three doses of glial maturation factor-beta (GMF-beta) directly in the lesion site. All subjects were then tested for twenty days on an active avoidance spatial alternation task. The behavioral recovery of the three groups of experimental animals was compared to that of animals having received the same brain damage and administration of a control substance (lesion controls), and to that of animals receiving a sham operation and no treatment (shams). The beneficial effects of administration were evident in the group of experimental animals receiving the lowest dose of GMF-beta. The performance of animals in this group was indistinguishable from that of the shams, and was significantly better than that of the lesion controls. The results suggest a behavioral role of GMF-beta which, in an in vitro system, is known to be a growth regulator of astroglial cells.

Blood-brain barrier breakdown and edema formation following frontal cortical contusion: does hormonal status play a role?

The present experiment was designed to evaluate and correlate the time course of blood-brain barrier (BBB) integrity and cerebral edema in adult male rats given medial frontal cortex contusions. The effect of sex hormones on BBB integrity in the same injury model was also examined, because previous work has shown that progesterone can reduce cerebral edema (Roof et al., 1993). BBB breakdown was assessed by Evans blue extravasation and albumin immunostaining while edema formation was measured by the wet weight dry weight technique. These processes were examined beginning 2 h and continuing up to 10 days after injury. Our findings show that medial frontal contusion in rats produces changes in cerebral water content and opening of the BBB that endures at least 7 days postinjury. Although pseudopregnancy has been shown to reduce cerebral edema at day 1 postinjury, we did not find any evidence that this hormonal state is associated with BBB repair.