Human gastric epithelial cells contribute to gastric immune regulation by providing retinoic acid to dendritic cells.

Despite the high prevalence of chronic gastritis caused by Helicobacter pylori, the gastric mucosa has received little investigative attention as a unique immune environment. Here, we analyzed whether retinoic acid (RA), an important homeostatic factor in the small intestinal mucosa, also contributes to gastric immune regulation. We report that human gastric tissue contains high levels of the RA precursor molecule retinol (ROL), and that gastric epithelial cells express both RA biosynthesis genes and RA response genes, indicative of active RA biosynthesis. Moreover, primary gastric epithelial cells cultured in the presence of ROL synthesized RA in vitro and induced RA biosynthesis in co-cultured monocytes through an RA-dependent mechanism, suggesting that gastric epithelial cells may also confer the ability to generate RA on gastric dendritic cells (DCs). Indeed, DCs purified from gastric mucosa had similar levels of aldehyde dehydrogenase activity and RA biosynthesis gene expression as small intestinal DCs, although gastric DCs lacked CD103. In H. pylori-infected gastric mucosa, gastric RA biosynthesis gene expression was severely disrupted, which may lead to reduced RA signaling and thus contribute to disease progression. Collectively, our results support a critical role for RA in human gastric immune regulation.

Comparison of 21 vs. 25 mm gastrojejunostomy in the gastric bypass procedure--early results.

BACKGROUND: Many bariatric surgeons consider a small gastrojejunostomy stoma critical to the success of gastric bypass. METHODS: We retrospectively compared a 21 vs. 25 mm gastrojejunostomy in 50 patients undergoing gastric bypass for morbid obesity. RESULTS: 31 patients were constructed with a 21 mm EEA, group I, and 19 with a 25 mm, group II. Average percent of excess body weight lost was 61%, 65%, and 64% at 12, 15, and 18 months follow-up in the group I patients, vs. 61%, 67%, and 69% in the group B patients. Differences were not significant. Complaints of nausea, vomiting, and/or dysphagia were similar between the groups. CONCLUSION: The choice of a 21 or 25 mm gastrojejunostomy does not appear to alter the success of gastric bypass surgery and can be based upon surgeon preference.

Left subclavian artery aneurysm: two cases of rare congenital etiology.

Subclavian artery aneurysms are uncommon. The most common causes of these aneurysms are atherosclerosis and traumatic pseudoaneurysm. We report two cases of rare congenial left subclavian artery aneurysms. Diagnosis with aortography and treatment with resection with bypass grafting are the optimal approaches to avoid life-threatening and limb-threatening ischemia.

Blunt cardiac trauma: atrioventricular valve disruption and ventricular septal defect.

Nonpenetrating cardiac trauma resulting in cardiac chamber or valvar rupture is uncommon, requiring a high degree of suspicion for diagnosis. A case involving avulsion of the tricuspid and mitral papillary muscles with resultant interventricular septal rupture is reported. This case illustrates the importance of transesophageal echocardiography in the rapid diagnosis of blunt cardiac trauma. Surgical treatment of this condition is also discussed.

Glutamine supplementation of enteral nutrition: impact on whole body protein kinetics and glucose metabolism in critically ill patients.

BACKGROUND: Glutamine-supplemented parenteral nutrition has been reported to attenuate the early postoperative reduction in intracellular glutamine and improve protein synthesis and nitrogen balance. We investigated the effect of an enteral formula or protein and glucose kinetics and nitrogen balance in trauma patients. METHODS: The enteral formula (AlitraQ) provided a mean intake of 0.35 g of glutamine/kg body weight per day to 16 trauma patients and was compared with an isonitrogenous formula that provided a mean of 0.05 g of glutamine/kg body weight per day in 14 trauma patients. After 3 days of feeding, protein kinetics were measured using a 4-hour prime-continuous infusion of L-[1-13C]leucine. Glucose kinetics were measured during the same time interval using prime-continuous infusion of [U-14C]- and [6-3H]glucose. RESULTS: Nitrogen balance was not significantly different in the two groups. There were no significant differences in protein turnover, synthesis, and breakdown between the two groups. There were no significant differences in glucose turnover, oxidation, recycling, and percent of VCO2 from glucose oxidation between the two groups. CONCLUSIONS: Glutamine-enriched enteral formulas are well tolerated by the severely injured patient but provide no additional nutritional advantage compared with standard enteral formulas during the first 3 days of feeding immediately after trauma.

The high risk heart donor: potential pitfalls.

BACKGROUND: The use of potentially infected donor hearts has been advocated to extend the supply of available hearts for transplantation. METHODS: To determine whether bacterial transmission from donor to recipient can occur with heart transplantation, we reviewed our experience with the 347 patients who received 360 heart transplants in the Utah Transplant Affiliated Hospitals from 1988 to 1993. RESULTS: During this time, nineteen donors had positive blood cultures before harvest. Sixteen donors had gram-positive bacteremia: Staphylococcus epidermidis (n = 9), Staphylococcus aureus (n = 5), streptococcus (n = 2). Two donors had gram-negative bacteremia: serratia (n = 1) and acinetobacter (n = 1). One donor had blood cultures positive for both Escherichia coli and streptococcus. Infectious complications occurred in two of three recipients who received a heart from a donor with gram-negative bacteremia: Escherichia coli endocarditis, mediastinitis, sepsis and death in one, and serratia sepsis and mediastinitis in another. In each case the organisms and sensitivities were identical between donor and recipient. No infectious complications related to the donor heart occurred among the 16 recipients who received hearts from donors with gram-positive bacteremia. CONCLUSIONS: (1) Bacterial transmission from donor heart to recipient can occur, (2) bacterial transmission appears to be more common with gram-negative organisms, and (3) infection of the recipient with a gram-negative organism from the donor heart is associated with significant morbidity and mortality.

Tricuspid valve dysfunction in the transplanted heart.

Mild degrees of tricuspid regurgitation are common in the orthotopically transplanted heart, probably secondary to the geometry of the right atrial anastomosis. At the University of Utah, 5 (0.95%) of 526 patients with transplantations performed from March 1985 to December 1993 have presented with severe tricuspid regurgitation requiring operative intervention. Echocardiographic findings confirmed at the time of operation consisted of ruptured chordae to the tricuspid valve. Standard tricuspid valve repair and replacement techniques were used with good results. We postulate the chordal disruption found in these patients is secondary to injuries incurred at the time of endomyocardial biopsy.

Laparoscopic retrieval of spilled stones.

Spillage of gallstones during laparoscopic cholecystectomy is occasionally a problem. The use of a finger cut off of a size 9 sterile glove as an intraperitoneal sack facilitates the removal of these stones.