Caudal anesthesia in a patient with peritonitis: Is it safe??

Neuraxial anesthesia combined with general anesthesia has become a widely accepted method of providing effective postoperative analgesia and decreasing intraoperative anesthetic needs in the pediatric population. In clinical practice, there still appears to be hesitancy for the use of a neuraxial technique (spinal or epidural) in patients at risk for bacteremia or with an on-going systemic infection. However, evidence-based medicine lacks any data to support an increase in the risk of infectious complications following neuraxial anesthesia. We present two pediatric patients with intra-abdominal infectious processes who received caudal epidural blockade for postoperative operative analgesia. The use of neuraxial techniques in patients at risk for bacteremia is reviewed, evidence-based medicine regarding the risks of infection discussed, and the potential favorable effects of neuraxial blockade on the neurohumoral response to sepsis and the systemic inflammatory responses presented.

Mass drug administration of azithromycin for trachoma reduces the prevalence of genital Chlamydia trachomatis infection in the Solomon Islands.

OBJECTIVES: Chlamydia trachomatis is the most common bacterial sexually transmitted infection and is frequently asymptomatic; ocular C. trachomatis strains cause trachoma. Mass drug administration (MDA) of azithromycin for trachoma might also reduce the prevalence of genital C. trachomatis. In a survey conducted in the Solomon Islands in 2014, prior to MDA, the prevalence of genital C. trachomatis was 20.3% (95% CI 15.9% to 25.4%). We conducted a survey to establish the impact of MDA with azithromycin on genital C. trachomatis. METHODS: Women attending three community outpatient clinics, predominantly for antenatal care, 10 months after MDA with azithromycin given for trachoma elimination, were enrolled in this survey. Self-taken high vaginal swabs were for C. trachomatis and Neisseria gonorrhoeae using the BD Probetec strand displacement assay. RESULTS: 298 women were enrolled. C. trachomatis infection was diagnosed in 43 women (14.4%, 95% CI 10.6% to 18.9%) and N. gonorrhoeae in 9 (3%, 95% CI 1.4% to 5.7%). The age-adjusted OR for C. trachomatis infection was consistent with a significant decrease in the prevalence of C. trachomatis following MDA (OR 0.58, 95% CI 0.37 to 0.94, p=0.027). There was no change in the prevalence of N. gonorrhoeae between following MDA (OR 0.51, 95% CI 0.22 to 1.22, p=0.13). CONCLUSIONS: This study demonstrated a 40% reduction in the age-adjusted prevalence of genital C. trachomatis infection following azithromycin MDA for trachoma elimination.

Prevalence of sexually transmitted infections in female clinic attendees in Honiara, Solomon Islands.

OBJECTIVES: This study sought to determine the prevalence of common bacterial sexually transmitted infections, including Chlamydia trachomatis and Neisseria gonorrhoeae, in women attending clinics in the Solomon Islands. METHODS: We conducted a sexual health survey among women attending three nurse-led community outpatient clinics in August 2014, to establish the prevalence of bacterial sexually transmitted infections in female clinic attenders in Honiara, Solomon Islands. Vaginal swab samples were tested for infection with C. trachomatis and N. gonorrhoeae using a commercial strand displacement amplification assay. Serum samples were tested for syphilis. RESULTS: We enrolled 296 women, aged 16-49, attending three clinics. Knowledge of safe sexual practices was high but reported condom usage was low. The prevalence of infection with C. trachomatis was 20%. The prevalence of infection with N. gonorrhoeae and syphilis were 5.1% and 4.1%, respectively. CONCLUSIONS: Bacterial sexually transmitted infections are a major health problem in the Solomon Islands. Interventions are urgently needed.

Prognostic values of MUC-1 molecule expressing cytokine receptor-like epitope and DF3 in patients with gastric carcinoma.

As recently reported, DF3/MUC-1 molecules having cytokine receptor-like sequences (CRL) at the extracellular region, are likely to function in signal transduction pathways. To elucidate the functional significance of CRL expressed on the DF3/MUC1 molecule, immunohistochemical localization of CRL and/or DF3 was investigated in cases of 115 patients with gastric carcinomas, treated by surgical resection. CRL was detected in 65 of 115 patients (56.5%), DF3 in 85 (73.9%), and both DF3 and CRL in 52 (45.2%). The combined immunohistochemical analysis of CRL and/or DF3, revealed that simultaneous expression of DF3 and CRL (DF3+/CRL+) significantly correlated to lymph node metastasis and to blood vessel invasion, and that patients with DF3+/CRL+-tumors survived for a significantly shorter period after surgery than did the other three groups (DF3+/CRL-, DF3-/CRL+, and DF3-/CRL-). Multivariate analysis showed independent prognostic significance for DF3+/CRL+ expression (hazard ratio [HR]=2.733, P=0.0085), and surgical cure (HR=4.334, P=0.003). To investigate the biological role of the simultaneous expression of DF3 and CRL, we constructed DF3-/CRL+ (NR-MC-38) and DF3+/CRL+ (R-MC-38) cells by transducing a mouse colon adenocarcinoma cell line MC-38 expressing neither DF3 nor CRL with MUC-1 cDNA containing ten tandem repeats (R-MC-38) or MUC-1 cDNA devoid of tandem repeats (NR-MC-38). R-MC-38 (DF3+/CRL+) cells were more invasive than NR-MC-38 (DF3-/CRL+) and MC-38 (DF3-/CRL-) cells. When these transfectants were incubated with pAb CRL, the invasiveness of R-MC-38 (DF3+/CRL+) was strikingly elevated over the case with native MC-38 (DF3-/CRL-) and NR-MC-38 (DF3-/CRL+) cells. The pAb CRL-induced invasiveness of R-MC-38 cells was inhibited by adding mAb DF3 or CRL peptides together with pAb CRL. These results suggest that an expression of DF3/MUC1 is highly associated with cell-invasiveness, and the DF3/MUC1-associated invasiveness is amplified by CRL. Thus DF3+/CRL+-MUC-1 molecule seems to be closely involved in a poor prognosis for gastric cancer patients.

Metastatic skin cancer; a case with signet ring cell histology.

We report a 64-year-old Japanese man who developed metastatic skin cancer, in the form of 1-3 cm diameter dome-shaped tumours on his face and head. Histopathological examination demonstrated diastase-resistant periodic acid--Schiff and Alcian blue-positive signet ring cells, suggesting gastric carcinoma. Immunohistochemical staining showed that these cells were positive for carbohydrate antigen CA19-9.

The effect of dietary selenium deficiency on acute colorectal mucosal nucleotoxicity induced by several carcinogens in the rodent.

BACKGROUND: Selenium (SE) has been inversely associated with colon cancer risk. Two potential mechanisms of this effect were examined in a rodent short-term carcinogenesis assay: whether dietary SE deficiency altered the initiation aspect of carcinogenesis in the colon, and whether SE altered carcinogen metabolism. SETTING: Animal laboratory. SUBJECTS: 52 Sprague-Dawley rats, divided into a SE diet deficient group (0.002 parts per million; ppm) and a SE sufficient (0.2 ppm) group. ENDPOINTS: Weight, serum SE concentration, and karryorhectic index (KI), which is a measure of acute carcinogen induced nuclear toxicity in the colonic mucosa. METHODS: After three weeks of acclimation to the diets, eight animals from each dietary group were injected with one of the following: dimethylhydrazine (DMH), a colon specific carcinogen, its metabolite, methylazoxymethanol (MAM), or 0.9% sodium chloride. Twenty-four hours after injection the colons were removed, blood drawn, and the stained colons assayed for nuclear aberrations. RESULTS: No weight differences were generated by the dietary variations. Low-dietary SE resulted in serum SE declining markedly in the study period to 6 ng/ml versus 33 ng/ml in the SE sufficient group. Diet alone, and variations in weight gain, did not alter the KI. Both carcinogens greatly increased the KI in both the left and right colon. A SE-deficient diet was associated with a higher KI in both carcinogen groups in the right colon, with statistical significance for both the left and right colon in the MAM injection group. CONCLUSIONS: Dietary SE deficiency is associated with increased KI of the colon in MAM treated rats. SE, therefore, has a protective effect in the initiation phase of carcinogenesis.

Immunohistochemical localization of group II phospholipase A2 in human pancreatic carcinomas.

The immunohistochemical localization of group II phospholipase A2 (PLA2) in normal fetal and adult human pancreases, 5 chronic pancreatitis, and 30 pancreatic ductal carcinomas was investigated. Furthermore, pancreatic carcinoma cases were correlated with histologic type, tumor size, vascular involvement, lymphatic involvement, perineural invasion, lymph node metastasis, amount of interstitial tissue in the tumor, growth pattern of the tumor, and clinical stage. In the normal pancreases, almost all of acinar cells and a few cells of small and large ducts were immunoreactive in a supranuclear pattern. In chronic pancreatitis, immunoreactivity was retained in several acini, islet cells, and ductal cells, but the staining was diminished in acinal cells of atrophic lobules. A strong immunoreactivity was found in the cells of hyperplastic ducts. In pancreatic ductal carcinomas, the immunoreactivity was observed in 25 cases (83%). Eighteen of 25 (72%) immunoreactive cases showed a cytoplasmic granular or luminal surface pattern, both of which were not observed in the normal pancreas. Among the clinicopathological parameters of pancreatic cancer, the incidence of expression of this enzyme was significantly higher in infiltrative type cancers than in expansive and localized tumors. Furthermore, the expression of group II PLA2 was significantly higher in the tumor with larger amount of interstitial tissue than in that with smaller amounts of interstitial tissue. These results suggest that expression of group II PLA2 in human pancreatic ductal carcinomas is possibly involved in the proliferation of interstitial tissue directly or indirectly through prostaglandin production.

[A case of multiple tumors].

A 54-year-old man was admitted to our clinic for a further examination of rectal and liver tumors, after which a rectal cancer, a hepatocellular carcinoma (HCC), a hemangioma of the liver a retroperitoneal cyst, and a submucosal tumor of the stomach (SMT) were diagnosed by means of a colonoscopy, a gastroscopy, and US, CT, and angiography, these tests also revealing elevated CEA and AFP levels. A hepatic subsegmentectomy and a Miles's operation, as well as an enucleation of other liver tumors and an SMT, were performed and a retroperitoneal cyst was removed. The histopathological finding of the rectal cancer was a moderately differentiated adenocarcinoma, while the liver tumors were determined as being an HCC of the trabecular type, adenomatas revealing hyperplasia, a hemangioma, and the SMT showing a benign leiomyoblastoma.

Small polydisperse low density lipoproteins in familial hyperalphalipoproteinemia with complete deficiency of cholesteryl ester transfer activity.

Lipoprotein abnormalities were analyzed in 3 cases of marked hyperalphalipoproteinemia caused by complete deficiency of cholesteryl ester transfer activity. The probands were all men, aged 34, 43 and 48 years, respectively. The serum high density lipoprotein (HDL)-cholesterol levels of these patients were higher than 150 mg/dl (157-254 mg/dl), while serum total cholesterol levels ranged from 227 to 360 mg/dl. Sequential flotation-ultracentrifugation analysis disclosed that low density lipoprotein (LDL)-cholesterol was slightly decreased and that cholesteryl ester accumulated solely in the HDL2 fraction, which was also enriched with apolipoprotein E. Cholesteryl ester transfer activity was completely absent in all of these cases. High-performance liquid chromatography showed a decrease of LDL particle size in combination with a marked enlargement of HDL particle size. Analytical ultracentrifugation disclosed heterogeneity of LDL with the presence of small LDL subpopulations. We conclude that hyperalphalipoproteinemia due to complete deficiency of cholesteryl ester transfer activity is characterized by the presence of both small polydisperse LDL and markedly large HDL enriched with cholesteryl ester and apolipoprotein E.

Gastric cancer diagnosed by biopsy of the uterine cervix.

Biopsy of the uterine cervix from a 46-year-old woman who suffered from epigastric pain and weight loss showed metastatic adenocarcinoma. The primary site of the tumor was the stomach. At laparotomy, disseminated adenocarcinoma on the peritoneum and Krukenberg's tumor in the right ovary were found. A palliative partial gastrectomy, resection of the right ovary, and postoperative chemotherapy were performed. The possible mechanism of metastasis of extragenital cancer to the uterus is discussed.

Microbiological degradation of bile acids. The conjugation of a certain cholic acid metabolite with amino acids in Corynebacterium equi.

1. (4R)-4[4alpha-(2-Carboxyethyl)-3aalpha-hexahydro-7abeta-methyl-5-oxoindan-1beta-yl]valeric acid (II) could not be utilized by Arthrobacter simplex, even though the acid was one of the metabolites formed from cholic acid (I) by this organism. Therefore the further degradation of the acid (II) by Corynebacterium equi was investigated to identify the intermediates involved in the cholic acid degradation. 2. The organism, cultured in a medium containing the acid (II) as the sole source of carbon, produced unexpected metabolites, the conjugates of this original acid (II) with amino acids or their derivatives, although the yield was very low. These new metabolites were isolated and identified by chemical synthesis as the Na-((4R)-4-[4alpha-(2-carboxyethyl)-3a alpha-hexahydro-7a beta-methyl-5-oxoindan-1 beta-yl]-valeryl) derivatives of L-alanine, glutamic acid, O-acetylhomoserine and glutamine, i.e. compounds (IIIa), (IIIb), (IIId) respectively. 3. The possibility that the bacterial synthetic reaction observed in the acid (II) metabolism with C. equi is analogous to peptide conjugation known in both animals and higher plants is discussed. A possible mechanism for this bacterial conjugation is also considered.

Microbiological degradation of bile acids. The preparation of some hypothetical metabolites involved in cholic acid degradation.

1. To identify the intermediates involved in the degradation of cholic acid, the further degradation of (4R)-4-[4alpha-(2-carboxyethyl)-3aalpha-hexahydro-7abeta-methyl-5-oxoindan-1beta-yl]valeric acid (IVa) by Arthrobacter simplex was attempted. The organism could not utilize this acid but some hypothetical intermediate metabolities of compound (IVa) were prepared for later use as reference compounds. 2. The nor homologue (IIIa) and the dinor homologue (IIIb) of compound (IVa) were prepared by exposure of 3-oxo-24-nor-5beta-cholan-23-oic acid (I) and (20S)-3beta-hydroxy-5-pregnene-20-carboxylic acid (II) to A. simplex respectively. These compounds correspond to the respective metabolites produced by the shortening of the valeric acid side chain of compound (IVa) in a manner analogous to the conventional fatty acid alpha- and beta-oxidation mechanisms. Their structures were confirmed by partial synthesis. 3. The following authentic samples of reduction products of the oxodicarboxylic acids (IIIa), (IIIb) and (IVa) were also synthesized as hypothetical metabolities: (4R)-4-[3aalpha-hexahydro-5alpha-hydroxy-4alpha-(3-hydroxypropyl)-7abeta-methylindan-1beta-yl]valeric acid (Vb) and its nor homologue (VIIa) and dinor homologue (IXa);(4R)-4-[3Aaalpha-hexahydro-5alpha-hydroxy-4alpha-(3-hydroxypropyl)-7abeta-methylindan-1beta-yl]-pentan-1-ol (Vc); and their respective 5beta epimers (Ve), (VIIc), (IXc) and (Vf). 4. In connexion with the non-utilization of compound (IVa) by A. simplex, the possibility that not all the metabolites formed from cholic acid by a certain micro-organism can be utilized by the same organism is considered.