Dynamic retention: a technique for closure of the complex abdomen in critically ill patients.

Management of the open abdomen in the setting of massive visceral swelling or extensive intra-abdominal abscess may pose an extremely difficult surgical scenario. We herein describe the technique and results of dynamic-retention sutures used in 13 patients with abdominal catastrophes after trauma, vascular reconstruction, tumor extirpation, and intra-abdominal infection. Three of these patients died during their acute care hospitalization. The remaining 10 patients were discharged to home with no resultant fistulas and 1 recurrent hernia (10%). Dynamic-retention sutures provide a useful technique for the closure of the complex surgical abdomen. We observed a low complication rate. In properly selected patients, this technique avoids the use of mesh or additional surgical procedures such as skin grafting or plastic surgical reconstruction of the abdominal wall.

G207, modified herpes simplex virus type 1, kills human pancreatic cancer cells in vitro.

Pancreatic cancer is often fatal, and further effective therapeutic options are needed. This study was designed to assess whether the replication-restricted herpes simplex virus, G207, was effective in killing human pancreatic cancer cells in vitro. G207, a multimutated strain of herpes simplex virus type 1 carrying lacZ reporter gene, is capable of efficient cytolytic growth in many dividing cells, including certain tumor cells, but not in nondividing cells. Three human pancreatic cell lines, AsPC-1, MIA PaCa-2, and BxPC-3, were infected with G207 at different multiplicities of infection. After 24 hours, expression of the lacZ reporter gene was tested using a histochemical X-gal assay. In addition, cell lines were infected with G207 for 24 to 48 hours; then the virus obtained from cell pellets and media supernatant was used to infect Vero cells to obtain G207 titers by plaque assay. To assess whether increasing viral immediate early gene expression would improve cytolysis and virus production, similar experiments were performed with the addition of 0.5 mmol/L of hexamethylene bisacetamide (HMBA) 1 hour after viral infection. Finally, MTS cell viability assays were performed to measure viable cells at 24 to 96 hours post infection. The X-gal assay data revealed a viral dose-dependent b-galactosidase expression, indicating G207 infectivity and expression of the lacZ reporter gene. Plaque assays demonstrated a viral dose-dependent increase in plaque formation, indicating viral production from all three cell lines. In addition, HMBA data indicated a modest increase in viral production. The MTS assay data indicated a dose-dependent cytotoxicity for G207 in the cell lines tested. G207 infects, replicates in, and is cytotoxic to the above-listed human pancreatic cell lines in vitro and warrants therapeutic evaluation in models of pancreatic cancer.

A newly recognized entity: intraductal "oncocytic" papillary neoplasm of the pancreas.

Intraductal papillary-mucinous tumors of the pancreas are increasingly recognized, and their characteristic endoscopic and radiological features are well reported in the literature in recent years. Oncocytic features in these tumors are uncommon and unrecognized. Intraductal oncocytic papillary neoplasm is a distinct pancreatic tumor and is a recently recognized entity. We report a case of a 69-yr-old patient who presented with symptoms mimicking pancreatitis, resulting in delay in the diagnosis of her pancreatic tumor. She underwent a successful Whipple's procedure and subsequently has remained well. The resected specimen showed an intraductal oncocytic papillary-mucinous neoplasm. The entity is new and the literature information is inadequate at present to judge the biological behavior of this tumor. We discuss this recently recognized entity.

Myocardial heat shock gene expression in pigs is dependent on superoxide anion generated at reperfusion.

The heat shock response is a conserved response to cell injury. We sought to determine if ischemia alone versus events at reperfusion stimulated expression of the major heat shock protein (hsp-72) in a clinically relevant model of global myocardial ischemia in pigs. Pigs were placed on nonpulsatile cardiopulmonary bypass. Serial transmural cardiac biopsies were taken at baseline following 20 min of normothermic global ischemia (induced by crossclamping the aorta) and at 20, 40, and 60 min of reperfusion. Test animals received a bolus and subsequent aortic root infusion of superoxide dismutase (total 7,500 U/kg) beginning just prior to reperfusion. Hsp-72 mRNA abundance was estimated from Northern blots. We found that hsp-72 mRNA was not induced following 20 min of ischemia but accumulated to high levels within 20 min of reperfusion. Intravascular administration of superoxide dismutase at reperfusion eliminated hsp-72 mRNA induction. We conclude that in the postischemic myocardium, hsp-72 gene expression is dependent on superoxide anion generation at reperfusion. In this setting, hsp-72 gene expression may reflect a specific response to oxidative injury rather than a more general response to metabolic stress associated with ischemia.

Induction of heat-shock gene expression in postischemic pig liver depends on superoxide generation.

BACKGROUND/AIMS: Both hemorrhagic and cardiogenic shock are associated with hepatic shock gene expression at resuscitation. This study investigated the potential role of intravascular superoxide anion as a proximal trigger of heat shock protein gene expression. METHODS: Preanesthetized pigs were subjected to 120 m of total warm hepatic ischemia. The survival model consisted of warm, total hepatic ischemia and reperfusion (with active portal-systemic bypass) followed by reperfusion and survival for 3 days. Serial hepatic biopsy samples were evaluated for the expression of heat shock protein 72 (HSP-72) messenger RNA (mRNA) by Northern and Western analysis and by in situ RNA hybridization. The possible role of intravascular O2- as a mediator of heat shock response was evaluated by its specific inhibition by the intravenous infusion of recombinant human superoxide dismutase (SOD). RESULTS: Ischemia for 120 minutes followed by 60 minutes of reperfusion caused accumulation of HSP-72 mRNA. Transcripts were localized to hepatocytes. HSP-72 mRNA was detected neither following ischemia alone nor when SOD was infused for 15 minutes at reperfusion. Three days later, transcripts were not detectable, but HSP-72 protein accumulated irrespective of SOD administration. CONCLUSIONS: Warm hepatic ischemia induces the hepatocyte expression of HSP-72 at reperfusion by a mechanism that is dependent upon the superoxide anion, probably generated intravascularly. However, the transient dismutation of superoxide is insufficient to suppress subsequent accumulation of HSP-72.

Regulation of acute phase gene expression following surgery and endotoxin administration in the anesthetized pig.

BACKGROUND: The hepatic acute phase response (APR) reflects an organism's integrated response to stress. This APR results in augmented synthesis and secretion of specific procoagulants and antiproteases and a complementary decrease in the synthesis and secretion of several constitutive proteins, such as albumin. The cytokines tumor necrosis factor (TNF) or interleukin-6 (IL-6) have been identified as proximal mediators of the APR in response to endotoxin stress. The authors hypothesized that TNF, IL-6, or both would be the proximal mediators of the APR in response to anesthesia and surgical stress. METHODS: The effects of a standardized surgical stress on the APR in pigs under general anesthesia with sodium pentobarbital and ketamine hydrochloride was investigated. Acute phase gene transcription was assayed in nuclei from serial liver biopsies obtained before and after 2.5 h of surgical stress, and after endotoxin administration. Tumor necrosis factor and IL-6 mRNA levels in this liver tissue were examined by Northern blot hybridization, and simultaneous plasma levels of these cytokines were measured using bioassays. RESULTS: The transcription rates of three positive acute phase genes--chymotrypsin inhibitor, inter-alpha-trypsin inhibitor and beta-fibrinogen--increased seven-, six-, and twofold, respectively (P < 0.05), and the transcription rate of albumin, a negative acute phase gene, decreased to 34% of baseline (P < 0.01) during the 2.5 h of anesthesia and surgical stress. During this initial 2.5 h, plasma concentrations of TNF and IL-6 did not change. Hepatic IL-6 mRNA expression was never observed, and TNF mRNA expression was undetectable in six of seven pigs. Subsequent 10-micrograms/kg endotoxin administration caused 20- and 100-fold increases in plasma concentrations of TNF and IL-6, respectively (P < 0.01), and were associated with substantial hepatic expression of the TNF and IL-6 mRNAs. These increments in cytokines were not associated with any further increase in the acute phase gene transcription rates. Thus, the APR was initially regulated at the transcriptional level during surgical stress independent of, and not augmentable by, an endotoxin-provoked increase in either plasma levels or hepatic mRNA expression of TNF or IL-6. CONCLUSIONS: Surgical stress induced hepatic acute phase gene transcription within 2.5 h in the absence of either systemic or local (hepatic) increases in TNF or IL-6. Subsequent endotoxin-induced increases in TNF or IL-6 did not alter this surgical stress-induced acute phase gene transcription.

Heat-shock gene expression excludes hepatic acute-phase gene expression after resuscitation from hemorrhagic shock.

BACKGROUND: To determine whether the gene expression of both acute-phase reactants (APR) and the major heat-shock protein (hsp-72) can occur simultaneously, transcriptional rates were measured during shock and resuscitation. METHODS: A nuclear runoff technique was applied to hepatic biopsy specimens obtained from pigs before shock, during 40% blood volume hemorrhagic shock (1 and 2 hours), and after resuscitation (4 and 6 hours). RESULTS: Shock-induced transcription of hsp-72 was elevated elevenfold over sham operation at 2 hours (p less than 0.02, Mann-Whitney rank test). Individually shocked animals did not transcribe both classes of stress genes but segregated into two groups: (1) strong APR transcriptional responders and (2) hsp-72 transcriptional responders. In group 2, APR transcription was significantly suppressed. Antichymotrypsin transcription was an average of eighteenfold lower in group 2 versus group 1 (p less than 0.05 at 1,2, and 6 hours). CONCLUSIONS: Different classes of stress protein genes are not transcribed simultaneously. We infer that their increased accumulation at the mRNA level is the result of sequential transcription. Hsp-72 transcription excludes that of the APR genes that may be critical to survival after stress.

4.5S RNA is encoded by hundreds of tandemly linked genes, has a short half-life, and is hydrogen bonded in vivo to poly(A)-terminated RNAs in the cytoplasm of cultured mouse cells.

4.5S RNA is a group of RNAs 90 to 94 nucleotides long (length polymorphism due to a varying number of UMP residues at the 3' end) that form hydrogen bonds with poly(A)-terminated RNAs isolated from mouse, hamster, or rat cells (W. R. Jelinek and L. Leinwand, Cell 15:205-214, 1978; F. Harada, N. Kato, and H.-O. Hoshino, Nucleic Acids Res. 7:909-917, 1979). We have cloned a gene that encodes the 4.5S RNA. It is repeated 850 (sigma = 54) times per haploid mouse genome and 690 (sigma = 59) times per haploid rat genome. Most, if not all, of the repeats in both species are arrayed in tandem. The repeat unit is 4,245 base pairs long in mouse DNA (the complete base sequence of one repeat unit is presented) and approximately 5,300 base pairs in rat DNA. This accounts for approximately 3 X 10(6) base pairs of genomic DNA in each species, or 0.1% of the genome. Cultured murine erythroleukemia cells contain 13,000 molecules per cell of the 4.5S RNA, which can be labeled to equilibrium in 90 min by [3H]uridine added to the culture medium. The 4.5S RNA, therefore, has a short half-life. The 4.5S RNA can be cross-linked in vivo by 4'-aminomethyl-4,5',8-trimethylpsoralen to murine erythroleukemia cell poly(A)-terminated cytoplasmic RNA contained in ribonucleoprotein particles.