Morel Lavallée Lesion - A case report and review of literature.

INTRODUCTION: Morel-Lavallée lesion (MLL) is an uncommon entity, by which shearing forces result in a closed degloving lesion. This can result in an infected hematoma and lead to a life-threatening situation. PRESENTATION OF CASE: We present a case of a 59-year-old patient who presented to our emergency department. This patient had a crushing injury, and later was found to have an infected MLL. The patient was treated with surgical drainage, and 2 split thickness skin grafts. The patient fully healed. DISCUSSION: We review the current literature regarding MLL and diagnostic tools in order to accurately and rapidly diagnose this often-missed entity. Special emphasis is given to the treatment of MLL, with the current knowledge as reflected in the literature. CONCLUSIONS: It is important for caregivers to know the diagnostic steps and pitfalls of this elusive diagnosis in order to diagnose and treat MLL quickly, before it turns into a life-threatening state for the patient.

Disparities in survival after trimodality therapy for esophageal adenocarcinoma.

Trimodality therapy with neoadjuvant chemoradiation followed by surgery has emerged as the standard of care for the treatment of locally advanced esophageal cancer. Yet, there is considerable variation in survival within this population. We sought to analyze factors associated with survival after trimodality therapy in esophageal adenocarcinoma. We identified 4,679 patients from the National Cancer Database (NCDB) of the American College of Surgeons who received chemotherapy and radiation prior to surgery for esophageal adenocarcinoma from 2006 to 2013. We excluded patients with stage IV disease and unknown pathological nodal status. We performed regression analyses using a Cox proportional hazards model to identify independent predictors of overall survival. On multivariate analysis, pathologic characteristics associated with decreased overall survival included stage, lymphovascular invasion, and positive surgical margins. Insurance status, age, and comorbidity index were also associated with decreased survival. We found that pathologically node-positive patients who received additional adjuvant chemotherapy were associated with improved survival. Compared to private insurance, Medicaid (HR 1.45, CI 1.22-1.73, P < 0.0001), Medicare (HR 1.17, CI 1.04-1.31, P = 0.0082), or having no insurance (HR 1.50, CI 1.17-1.92, P = 0.0012) were all negative predictors of overall survival. In patients with esophageal adenocarcinoma who have undergone trimodality therapy, a number of different factors are associated with overall survival. In particular, socioeconomic factors relating to access to care are independent predictors of survival. Despite receiving the standard of care, treatment disparities persist in this population of patients.

Birthplace and esophageal cancer incidence patterns among Asian-Americans.

The incidence of esophageal adenocarcinoma in the United States has risen rapidly over the last 30 years, whereas the incidence of esophageal squamous cell carcinoma has fallen dramatically. In contrast, parts of Asia have extremely high rates of squamous cell carcinoma, but virtually no adenocarcinoma. Within the United States, Asian-Americans as a whole, have low rates of esophageal adenocarcinoma and higher rates of squamous cell carcinoma. It is unclear what the patterns are for those Asians born in the United States. The relative influence of ethnicity and environment on the incidence of esophageal cancer in this population is unknown. We identified all cases of esophageal adenocarcinoma and squamous cell carcinoma from the California Cancer Registry 1988-2004, including 955 cases among 6 different Asian ethnicities. Time trends were examined using Joinpoint software to calculate the annual percentage changes in regression models. Rates of esophageal squamous cell carcinoma varied substantially among different Asian ethnic groups, but squamous cell carcinoma was much more common than adenocarcinoma in both foreign-born and US-born Asian-Americans. Rates of squamous cell carcinoma were slightly higher among US-born Asian men (4.0 per 100,000) compared with foreign-born Asian men (3.2 per 100,000) and White men (2.2 per 100,000), P = 0.03. Rates of adenocarcinoma were also slighter higher among US-born Asian men (1.2 per 100,000) compared with foreign-born Asian men (0.7 per 100,000), P = 0.01. Rates of squamous cell carcinoma decreased for both US-born and foreign-born Asians during this period, whereas adenocarcinoma remained low and stable. These results provide better insight into the genetic and environmental factors affecting the changing incidence of esophageal cancer histologies in the United States and Asia.

The FEN1 E359K germline mutation disrupts the FEN1-WRN interaction and FEN1 GEN activity, causing aneuploidy-associated cancers.

Polymorphisms and somatic mutations in Flap Endonuclease 1 (FEN1), an essential enzyme involved in DNA replication and repair, can lead to functional deficiencies of the FEN1 protein and a predisposition to cancer. We identified a FEN1 germline mutation that changed residue E359 to K in a patient whose family had a history of breast cancer. We determined that the E359K mutation, which is in the protein-protein domain of FEN1, abolished the interaction of FEN1 with Werner syndrome protein (WRN), an interaction that is critical for resolving stalled DNA replication forks. Furthermore, although the flap endonuclease activity of FEN1 E359K was unaffected, it failed to resolve bubble structures, which require the FEN1 gap-dependent endonuclease activity. To determine the etiological significance of E359K, we established a mouse model containing this mutation. E359K mouse embryonic fibroblasts (MEF) were more sensitive to DNA crosslinking agents that cause replication forks to stall. Cytological analysis suggested that the FEN1-WRN interaction was also required for telomere stability; mutant cell lines had fragile telomeres, increased numbers of spontaneous chromosomal anomalies and higher frequencies of transformation. Moreover, the incidence of cancer was significantly higher in mice homozygous for FEN1 E359K than in wild-type mice, suggesting that the FEN1 E359K mutation is oncogenic.

Side-to-side stapled intra-thoracic esophagogastric anastomosis reduces the incidence of leaks and stenosis.

Trans-hiatal esophagectomy with a hand-sewn anastomosis was for 2 decades the preferred approach in our institution for patients with esophageal cancer. In our experience, this anastomotic technique was associated with a 12% leak rate and a 48% rate of stricture requiring dilatation. We sought to determine if a side-to-side intra-thoracic anastomosis was associated with a lower rate of anastomotic stricture and leak. Thirty-three consecutive patients with distal esophageal cancer or Barrett's esophagus with high grade dysplasia underwent a trans-thoracic esophagectomy with a side-to-side stapled intra-thoracic anastomosis. The overall morbidity was 27%, with no anastomotic stricture or leaks. One patient died (3%). The median time to the resumption of an oral diet was 7 days (range 5-28), and the median length of stay in hospital was 9 days (range 6-45). Trans-thoracic esophagectomy with a side-to-side stapled anastomosis is safe and it is associated with a very low rate of anastomotic complications. We consider this to be the procedure of choice for patients with distal esophageal cancers.

Effects of intralipid infusion on blood viscosity and other haemorheological parameters in neonates and children.

AIM: To study acute haemorheological effects of intralipid in preterm and full-term neonates and children. Circulatory complications of intralipid infusion, such as increases in pulmonary and peripheral flow resistance, have been associated with impaired blood rheology. METHODS: During total parenteral nutrition, 10 preterm infants, 10 full-term neonates and 10 children received an initial dose of intralipid as continuous infusion (0.6 g/kg) over 4 h. Additionally, blood of 10 healthy preterm infants, 10 full-term neonates and 10 adults was incubated with intralipid. Whole blood and plasma viscosity (capillary viscometer), red blood cell (RBC) deformability (rheoscope) and RBC aggregation (Myrenne aggregometer) were measured before and after intralipid infusion and before and after in vitro incubation of blood with intralipid. RESULTS: During intralipid infusion, plasma triglyceride levels increased from 0.13 +/- 0.27 to 2.16 +/- 0.68 g/l in the preterm infants, from 0.14 +/- 0.21 to 1.64 +/- 0.54 g/l in the full-term neonates and from 0.65 +/- 0.31 to 2.26 +/- 0.60 g/l in the children. Whole blood viscosity decreased by about 10% after intralipid in all three groups due to similar decreases in haematocrit. RBC aggregation decreased by about 20% after intralipid infusion. Plasma proteins, plasma viscosity and RBC deformation were not affected by intralipid. In vitro incubation of blood with intralipid resulted in a marked reduction of RBC aggregation that was related to the intralipid concentration. At intralipid concentrations of 4 and 8 mg/ml, no RBC aggregation was noted in preterm and full-term neonates. In adults, RBC aggregation decreased by 50%. CONCLUSIONS: Previously described deleterious effects of intralipid on circulation can not be explained by changes in haemorheological properties.

Intraocular pressure and tear production in five herbivorous wildlife species.

The intraocular pressure and rate of tear production were measured in 18 addax antelopes (Addax nasomaculatus), four impalas (Aepyceros melampus), 11 wide-lipped rhinoceroses (Ceratotherium simum), 10 white-tailed wildebeests (Connochaetes gnou) and seven scimitar-horned oryxes (Oryx dammah). The animals were anaesthetised with an intramuscular injection of etorphine hydrochloride and acepromazine maleate, and the Schirmer tear test I was used to evaluate tear production, and applanation tonometry was used to evaluate the intraocular pressure. The mean (sd) rate of tear production ranged from 17.6 (3.1) mm/minute in the rhinoceros to 28.8 (8.3) mm/minute in the addax. The intraocular pressure ranged from 8.0 (1.2) mmHg in the impala to 32.1 (10.4) mmHg in the rhinoceros. The rate of tear production in the addax and the intraocular pressure in the rhinoceros appear to be the highest values of these variables to have been reported in any species.

The effect of 0.12% unoprostone isopropyl (rescula) on intraocular pressure in normotensive dogs.

Rescula (0.12% unoprostone isopropyl) is the first docosanoid compound approved for treatment of glaucoma in humans. It is commercially available in Japan, and is undergoing clinical testing elsewhere. The aim of this study was to evaluate the effect of Rescula on intraocular pressure (IOP) in normotensive dogs. After establishing a baseline diurnal IOP curve, six dogs were unilaterally treated with Rescula while the contralateral eye was treated with a placebo. Applanation tonometry was performed in both eyes, and pupil size was evaluated, 30 min after treatment, and at 1-hr intervals for the next 9 hr. Rescula caused a significant (p=0.014) and long-lasting decrease in IOP, from 20.49+/-2.02 mm Hg in control eyes to 15.49+/-0.69 mm Hg in treated eyes. These results suggest that Rescula is potentially efficacious in treatment of canine glaucoma.

Effects of melatonin ingestion on cAMP and cGMP levels in human plasma.

The effects of daytime melatonin treatment (0.3 mg) on cAMP and cGMP levels in platelet-rich plasma (PRP) and platelet-poor plasma (PPP) were investigated in 14 normal human subjects (age+/-s.e.m. 26.2+/-3. 2 years). Plasma levels of cAMP, cGMP and melatonin were measured before and at intervals for 3 h after the treatment was administered at 1300 h. Plasma melatonin concentrations reached peak levels 1 h after the treatment (mean+/-s.d. 182.3+/-43.5 pg/ml). The mean areas under the curve (AUC) for the time-cGMP concentration curves in PPP and in PRP were significantly increased after melatonin treatment compared with those observed after placebo treatment (P=0.001). No significant difference in cGMP levels was observed between PPP and PRP. Increase in self-reported sleepiness after melatonin treatment positively correlated with increase in plasma cGMP levels (r=0.92). The mean AUC for the time-cAMP concentration in PRP, but not in PPP, was increased 1 h after melatonin treatment compared with that observed after placebo treatment, but not thereafter. No correlation between individual PRP or PPP cAMP levels and subjective sleepiness was observed. These results demonstrate a stimulating effect of melatonin treatment on plasma cGMP levels in humans and suggest a correlation between the increase in circulating cGMP levels and the sleep-promoting effect of the pineal hormone.

Efficacy of Fluazinam in Suppression of Monosporascus cannonballus, the Causal Agent of Sudden Wilt of Melons.

Sudden wilt (vine decline) of melon, caused by Monosporascus cannonballus, is a worldwide problem in arid and semi-arid regions. Soil disinfestation by fumigation with methyl bromide before planting is a common treatment for disease management but, because methyl bromide is expected to be banned from use within the next 10 years, alternative measures for disease suppression are needed. The efficacy of 29 fungicides against M. cannonballus was evaluated in vitro. Among the fungicides tested, fluazinam and kresoxim methyl were the most effective and both totally inhibited the growth of M. cannonballus in culture at concentrations of 10 µg a.i /ml. Because fluazinam also was effective in inhibition of Pythium aphnidermatum, which also may be involved in sudden wilt syndrome, and kresoxim methyl was not, fluazinam was chosen for further tests. The effective dose of fluazinam for M. cannonballus that reduced mycelial growth by 50% was 0.09 µg a.i./ml. Fluazinam efficacy was evaluated in three field experiments conducted in the spring and in the late summer cropping seasons. In two of the experiments, applications of fluazinam resulted in approximately 87% wilt reduction, whereas in the third experiment it was only 32%. The mobility of fluazinam in soil was determined in samples taken from the field. Fungicide mobility in soil was relatively limited; most of the compound was adsorbed to soil particles, resulting in a zone of high concentration that decreased with depth and distance from the application site. Nevertheless, rates measured even at a depth of 25 cm were sufficient to control M. cannonballus. This study shows that fluazinam may be used as one component in an integrated approach for suppression of sudden wilt of melons.

[Psychotherapy combined with use of the vacuum constrictive device for erectile impotence].

Psychotherapy and the vacuum constriction device were used to treat 125 men with different types of erectile impotence. 58 came with their wives (Group 1), the wives of 49 did not agree to come (Group 2), and 18 men did not want to inform their wives of their condition (Group 3). Age ranges and means for the 3 groups were, respectively: 26-82 (56.2 +/- 2.8); 24-80 (53.1 +/- 2.2); and 25-76 (59.3 +/- 2.7). All groups received 6-10 combined treatments, and in all 3 groups there was improvement in the objective parameters of sexual function (nocturnal penile tumescence, penile brachial index, maximal penile rigidity). But only in Group I was there improvement in subjective parameters (spontaneous erection, adequate coitus without the vacuum device). After treatment, successful coitus, with or without use of the device, was achieved in 91.3% of Group I, 69.3% of Group II and 50.0% of Group III. These results indicate that regardless of type of erectile impotence, the greatest degree of success is achieved when the patient comes for treatment together with his wife.

[Treatment of erectile dysfunction with vacuum constriction device].

The vacuum constriction device (VCD) is a noninvasive mechanical device which may produce an erection by creating a vacuum of up to 250 mm Hg and with a rubber ring to maintain this state by constricting the base of the penis. We tested the VCD on 150 men who presented with organic and psychogenic impotence in our outpatient clinic between the years 1986 and 1992. Of the 150 men, 113 (75%) achieved an adequate erection with the VCD. However, only 72 patients agreed to buy the device and use it regularly. During follow-up of from 3 months to 5 1/2 years (mean 25 months), 65 men were using the VCD regularly and reported satisfying intercourse at least once every 2 weeks. Complications were minimal and consisted of mild numbness of the penis in 7 patients, mild cyanosis in 17, and 10 cases of painless ecchymoses and petechiae which disappeared without any treatment. From our experience, the VCD appears to be a safe, inexpensive, and easy method for impotent men to engage in sexual intercourse without, of course, eliminating other therapeutic options, including surgery.

Denial, locus of control and depression among physically disabled and nondisabled men.

The Denial and the Depression scales of the MMPI and Rotter's Locus of Control scale were administered to 26 men with locomotor disabilities and to 44 nondisabled men. Among the disabled, brain-damaged scored higher in the Denial scale than the non-brain-damaged disabled, but not higher than the nondisabled Ss. A fairly high correlation was found between Denial and Locus of Control. The more the S believed that he is externally controlled, the less denial he employed. All disabled groups scored significantly higher on the Depression scale than the nondisabled group. The latter finding is discussed in terms of two behavioral formulations of depression.

Soft hydrophilic contact lenses in civil and military aviation.

This study was undertaken to evaluate that possible acceptability of the hydrophilic contact lenses, both in military and civil aviation. Twelve volunteers, senior pilots of both military and civilian aircraft, were accepted for the first phase of this study. Hydrophilic contact lenses were evaluated in different flights conditions, including different altitudes, pressures and humidities, as well as the effects of light and glare and the special tasks of military flight. Although the series investigated is small, the results obtained indicate that hydrophilic contact lenses may favorably replace regular spectacles worn by pilots of military or civilian aircraft.