Embolization of a large progressive symptomatic desmoid tumor in the rectus muscle of a female patient with multiple sclerosis: a case report.

INTRODUCTION: Desmoid tumors are benign tumors, yet can lead to significant morbidity due to aggressive local expansions. Treatment starts with a wait-and-see policy, however, more aggressive treatments like broad margin resection surgery might be necessary in case of tumor progression. PATIENTS AND METHODS: We report the case of a 26-year-old female with a symptomatic desmoid tumor in the left rectus muscle. The initial wait-and-see policy led to an increase in tumor size and progression of symptoms. Computed tomography (CT) angiography revealed a dominant arterial blood supply via a branch of the inferior epigastric artery. We then performed a super selective embolization of the dominant arterial blood supply, to avoid the need for broad margin resection. RESULTS: At three months follow-up, the patient was asymptomatic and magnetic resonance imaging (MRI) showed no residual tumor. At nine months follow-up, MRI scan reconfirmed the successful outcome. CONCLUSIONS: Embolization of a primary supplying vessel of a desmoid tumor is a viable treatment option. However, scientific evidence remains limited and further research is mandatory for inclusion in evidence based treatment algorithms.

Is FNAC (fine needle aspiration cytology) a useful tool in detection of malignancy in thyroid surgery? A single institution experience.

OBJECTIVE: To evaluate if FNAC (Fine Needle Aspiration Cytology) is a useful tool in the detection of malignancy in thyroid surgery. FNAC is used routinely as a preoperative diagnostic technique and surgical strategy is often adapted. But is FNAC such a good technique in defining surgical strategy? METHODS: We retrospectively reviewed all files of 703 patients operated from 1997 till today. We obtained the results of the FNAC, the final pathological diagnosis and these data were analyzed. RESULTS: There were 161 male and 542 female patients. 72 out 703 patients had a malignancy. 241 patients (34.3%) had a preoperative FNAC-procedure. Male patients had significantly more malignancies (p = 0.006). In 183 patients (75.9%) the FNAC was benign, 28 patients (11.6%) showed malignancy, in 15 patients (6.2%) only blood was found and 15 patients (6.2%) showed an inconclusive result. 70.1% of the patients were true negative, 5.8% were true positive, 5.8% false positive, 5.8% false negatives, 5.8% of inconclusive results were malignant on pathology. This gives a sensitivity of 50% and specificity of 92.4%. CONCLUSIONS: The specificity of FNAC in malignancy is high (92.4%) but a sensitivity of 50% is low. With these results adaptation of surgical strategy (hemithyroidectomy or total thyroidectomy) secondary to the results of the FNAC is not recommended. Free hand FNAC might be a reason for the relatively high percentage of inconclusive results. Ultrasound guided FNAC can improve the yield of the puncture. On top of that pathological interpretation of the cytology is not always straight forward.

A novel link between Campylobacter jejuni bacteriophage defence, virulence and Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is a post-infectious disease in which the human peripheral nervous system is affected after infection by specific pathogenic bacteria, including Campylobacter jejuni. GBS is suggested to be provoked by molecular mimicry between sialylated lipooligosaccharide (LOS) structures on the cell envelope of these bacteria and ganglioside epitopes on the human peripheral nerves, resulting in autoimmune-driven nerve destruction. Earlier, the C. jejuni sialyltransferase (Cst-II) was found to be linked to GBS and demonstrated to be involved in the biosynthesis of the ganglioside-like LOS structures. Apart from a role in pathogenicity, we report here that Cst-II-generated ganglioside-like LOS structures confer efficient bacteriophage resistance in C. jejuni. By bioinformatic analysis, it is revealed that the presence of sialyltransferases in C. jejuni and other potential GBS-related pathogens correlated significantly with the apparent degeneration of an alternative anti-virus system: type II Clusters of Regularly Interspaced Short Palindromic Repeat and associated genes (CRISPR-Cas). Molecular analysis of the C. jejuni CRISPR-Cas system confirmed the bioinformatic investigation. CRISPR degeneration and mutations in the cas genes cas2, cas1 and csn1 were found to correlate with Cst-II sialyltransferase presence (p < 0.0001). Remarkably, type II CRISPR-Cas systems are mainly found in mammalian pathogens. To study the potential involvement of this system in pathogenicity, we inactivated the type II CRISPR-Cas marker gene csn1, which effectively reduced virulence in primarily cst-II-positive C. jejuni isolates. Our findings indicate a novel link between viral defence, virulence and GBS in a pathogenic bacterium.

Thoraco-abdominal wall reconstruction after surgical debulking of a giant retroperitoneal liposarcoma: a case report.

A case of a patient with a recurrent dedifferentiated retroperitoneal liposarcoma with extensive invasion of the thoraco-abdominal wall including the skin, requiring reconstructive surgery after debulking of the tumor is reported.

Detection of colon flora in peritoneal drain fluid after colorectal surgery: can RT-PCR play a role in diagnosing anastomotic leakage?

A semi-quantitative Real-Time PCR strategy was developed to identify potential indicator organisms for anastomotic leakage in peritoneal drainage fluid, Escherichia coli and Enterococcus faecalis. The analytical performance of the amplification method was validated with 10 culture-positive and 7 culture-negative peritoneal drain fluid samples, obtained from 9 different patients with a colorectal anastomosis. Real-Time PCR results were fully concordant with the microbiological culture results. However, among the culture-negative samples, four false-positive RT-PCR results were found. All false-positives originated from a single patient with a surgical site infection. This may indicate an elevated sensitivity of the RT-PCR method. The results showed that the semi-quantitative RT-PCR method has a clear potential to be useful as a powerful tool in early detection of anastomotic leakage.

Incarcerated vesico-inguinal hernia: a case report.

In this paper we report a rare case of an incarcerated inguinoscrotal hernia of the urinary bladder in a 64-year-old male patient. He presented with a giant inguinal hernia and pollakisuria. The bladder was surgically repositioned intra-abdominally and resection of part of the bladder fundus was performed through laparotomy. Closure of the inguinal defect was performed through an inguinal approach. The patient's further recovery was uneventful. Herniation of the bladder is a very infrequent finding in inguinal hernias. We searched the literature and only found a few case reports describing this rare pathology. The literature and treatment options are discussed.

The mannose cap of mycobacterial lipoarabinomannan does not dominate the Mycobacterium-host interaction.

Pathogenic mycobacteria have the ability to persist in phagocytic cells and to suppress the immune system. The glycolipid lipoarabinomannan (LAM), in particular its mannose cap, has been shown to inhibit phagolysosome fusion and to induce immunosuppressive IL-10 production via interaction with the mannose receptor or DC-SIGN. Hence, the current paradigm is that the mannose cap of LAM is a crucial factor in mycobacterial virulence. However, the above studies were performed with purified LAM, never with live bacteria. Here we evaluate the biological properties of capless mutants of Mycobacterium marinum and M. bovis BCG, made by inactivating homologues of Rv1635c. We show that its gene product is an undecaprenyl phosphomannose-dependent mannosyltransferase. Compared with parent strain, capless M. marinum induced slightly less uptake by and slightly more phagolysosome fusion in infected macrophages but this did not lead to decreased survival of the bacteria in vitro, nor in vivo in zebra fish. Loss of caps in M. bovis BCG resulted in a sometimes decreased binding to human dendritic cells or DC-SIGN-transfected Raji cells, but no differences in IL-10 induction were observed. In mice, capless M. bovis BCG did not survive less well in lung, spleen or liver and induced a similar cytokine profile. Our data contradict the current paradigm and demonstrate that mannose-capped LAM does not dominate the Mycobacterium-host interaction.

Horizontal transmission of Mycobacterium avium subsp. paratuberculosis in cattle in an experimental setting: calves can transmit the infection to other calves.

In September 2001, two subsequent transmission experiments both lasting 3 months were carried out to study cow-calf transmission of Mycobacterium avium subsp. paratuberculosis (Map) (Period 1), followed by calf-calf transmission of the infection (Period 2). Every 2 weeks, serum, heparinised blood and faecal samples were collected from all animals. After these experiments, the 20 calves were housed individually for more than 3 years to be able to detect the infection status and excretion pattern of each animal. In autumn 2004, the animals were inseminated, to observe a possible increase in faecal excretion of Map shortly before expected calving. One month before the expected calving date in 2005, animals were slaughtered and several tissues per cow and unborn calf were sampled for culture. The results indicate that horizontal cow-calf transmission is readily achieved (Period 1). At the highest infection pressure (six shedding cows of which three high shedders in Period 1) all five calves excreted Map in their faeces during Period 1 (shortly after infection), and four of these calves during Period 2 (when the shedding cows were absent). After that, excretion became less frequently. Horizontal calf-calf transmission did take place (Period 2), as the four donor-calves infected two receiver-calves. Transmission rates during the 3 months periods were quantified as a reproduction ratio R. The R [95% CI] of cow-calf and calf-calf transmission were estimated as 2.7 [1.1, 6.6] and 0.9 [0.1, 3.2] new infections per infectious animal during 3 months.

Splenic abscess complicating infective endocarditis: three case reports.

We present three case-reports of splenic abscess in patients who were initially diagnosed with bacterial endocarditis. In all cases the diagnosis of splenic abscess was based on the findings of abdominal CT scan or MRI. All patients were treated by laparotomy and splenectomy. Two patients fully recovered and one patient, who suffered from splenic rupture and massive blood loss before surgery, died. Splenic abscess is a well-described but rare complication of infective endocarditis. Rapid diagnosis and treatment are essential as its course can prove fatal. Abdominal CT scan or MRI should be performed if there is clinical suspicion of splenic abscedation. Immediate splenectomy combined with appropriate antibiotics and valve replacement surgery is the treatment of choice. Splenic tissue is very fragile--especially if the abscess is located subcapsular--and a splenic rupture can result from minimal trauma. If the patient's general state allows it, it is best to perform splenectomy prior to valve replacement surgery to prevent re-infection of the valve prosthesis. A combined one-stage procedure is also an option.

Frozen section in thyroid surgery.

OBJECTIVE: We studied the use of frozen section in the detection of malignancy in thyroid surgery in a large teaching hospital. MATERIALS AND METHODS: We reviewed all case notes of patients operated on for thyroid disease between January 1st 1997 and December 31st 2004. We identified 420 operations in 408 patients. Data were available for 417 operations. RESULTS: In patients with a solitary thyroid nodule, a frozen section is sometimes performed. Frozen section was done in 128 of 417 operations. The specificity for malignancy was 98.16%. The positive predictive value was 81.81% and the negative predictive value 93.85%. However the sensitivity was 56.25%. Frozen section is a time-consuming investigation. With follicular lesions it is very difficult to distinguish between benign disease and malignancy since the diagnosis of malignancy depends on capsular and/or blood vessel invasion. Also it costs about 100 Euro (approximately 125 dollars). CONCLUSION: This study confirms that adequate histopathologic diagnosis of thyroid disease is based on extensive subsampling of the specimen which is not possible during a peroperatory frozen section procedure.

Specific and sustained down-regulation of genes involved in fatty acid metabolism is not a hallmark of progression to cardiac failure in mice.

Preferential and specific down-regulation of genes involved in fatty acid (FA) uptake and metabolism is considered a hallmark of severe hypertrophic remodeling and progression to cardiac failure. Therefore, we investigated the time course of changes in cardiac metabolic gene expression (1) in mice subjected to regional myocardial infarction (MI) for 4 days, 1 month, or 3 months and (2) in mice overexpressing calcineurin (Cn) which initially develop concentric hypertrophy progressing after the age of 4 weeks to dilated cardiomyopathy and failure. In both models, hypertrophy was characterized by increased expression of beta-myosin heavy chain protein and atrial natriuretic factor mRNA, indicative of marked structural remodeling. Fractional shortening progressively decreased from 31% to 15.1% and 3.7% 1 and 3 months after MI, respectively. One month post-MI, the expression of several metabolic genes, i.e., acyl-CoA synthetase (-50%), muscle-type carnitine palmitoyl transferase 1 (-37%) and citrate synthase (-28%), was significantly reduced in the surviving myocardium. Despite overt signs of cardiac failure 3 months post-MI, the expression of these genes had returned to normal levels. In hearts of both 4- and 6-week-old Cn mice, genes involved in both FA and glucose metabolism and mitochondrial citrate synthase were down-regulated, reflecting an overall decline in metabolic gene expression, rather than a specific and preferential down-regulation of genes involved in FA uptake and metabolism. These findings challenge the concept that specific and sustained down-regulation of genes involved in FA uptake and metabolism represents a hallmark of the development of cardiac hypertrophy and progression to failure.

A defunctioning stoma in the treatment of lower third rectal carcinoma.

INTRODUCTION: Total mesorectal excision (TME) is the accepted standard for rectal cancer treatment. However, there is an increased risk of symptomatic anastomotic leakage associated with TME as TME potentially endangers the blood supply of the remaining rectum. On top of this, many patients will receive neo-adjuvant radio-chemotherapy. A defunctioning stoma helps in avoiding severe complications of anastomotic failure. MATERIAL AND METHODS: We prospectively collected data of all patients with a rectal carcinoma within reach of the palpating finger, operated on in our department between December 2000 and January 2005. There were 70 patients (42 men and 28 women, median age 70 (range 32-95)). RESULTS: In 40 patients (40/70 = 57%) a sphincter-saving procedure was performed. Eleven patients were diagnosed with anastomotic leakage or failure. Seven patients had neo-adjuvant radio-chemotherapy, 4 had no neo-adjuvant therapy. In 4 patients signs of anastomotic leakage were seen on the barium-enema that is routinely performed before closing the defunctioning stoma. Seven patients (7/40 = 17,5%) had clinical signs of anastomotic leakage. Three of them could be treated conservatively with antibiotics and parenteral nutrition. Two of these patients did not have a defunctioning stoma. Four patients needed re-intervention and were treated in intensive care for several days. Three of these patients did not have a defunctioning stoma. CONCLUSION: Neo-adjuvant radio-chemotherapy and TME resection are two factors in the treatment of rectal cancer that might interfere with anastomotic healing in the case of a sphincter-saving procedure. The construction of a defunctioning stoma helps in limiting the complications of anastomotic leakage or failure.

Sensitive detection of Mycobacterium avium subsp. paratuberculosis in bovine semen by real-time PCR.

AIMS: To develop a fast and sensitive protocol for detection of Mycobacterium avium subsp. paratuberculosis (MAP) in bovine semen and to make a critical evaluation of the analytical sensitivity. METHODS AND RESULTS: Processed semen was spiked with known amounts of MAP. Semen from different bulls as well as semen of different dilutions was tested. The samples were treated with lysing agents and beadbeating and the DNA was extracted with phenol and chloroform. Real-time PCR with a fluorescent probe targeting the insertion element IS900 detected as few as 10 organisms per sample of 100 mul semen. PCR-inhibition was monitored by inclusion of an internal control. Pre-treatment with immunomagnetic separation was also evaluated, but was not shown to improve the overall sensitivity. CONCLUSIONS: Real-time PCR is a sensitive method for detection of MAP in bovine semen. Lysis by mechanical disruption followed by phenol and chloroform extraction efficiently isolated DNA and removed PCR-inhibitors. SIGNIFICANCE AND IMPACT OF THE STUDY: The high sensitivity of the applied method allows reliable testing of bovine semen used for artificial insemination to prevent the spread of Johne's disease, caused by MAP.

Functional and metabolic adaptation of the heart to prolonged thyroid hormone treatment.

In heart failure, thyroid hormone (TH) treatment improves cardiac performance. The long-term effects of TH on cardiac function and metabolism, however, are incompletely known. To investigate the effects of up to 28 days of TH treatment, male Wistar rats received 3,3',5-triiodo-l-thyronine (200 microg/kg sc per day) leading to a 2.5-fold rise in plasma fatty acid (FA) level and progressive cardiac hypertrophy (+47% after 28 days) (P < 0.001). Ejection fraction (echocardiography) was increased (+12%; P < 0.05) between 7 and 14 days and declined thereafter. Neither cardiac FA oxidation, glycolytic capacity (homogenates) per unit muscle mass, nor mRNA levels of proteins involved in FA and glucose uptake and metabolism (Northern blots and microarray) were altered. After 28 days of treatment, mRNA levels of uncoupling proteins (UCP) 2 and 3 and atrial natriuretic factor were increased (P < 0.05). This indicates that TH-induced hypertrophy is associated with an initial increase in cardiac performance, followed by a decline in cardiac function and increased expression of UCPs and atrial natriuretic factor, suggesting that detrimental effects eventually prevail.

Perforation due to ileocaecal salmonellosis.

A 54-year old male patient was admitted with a tentative diagnosis of biliary pancreatitis. After 3 days, he developed an acute abdomen with a pneumoperitoneum. A laparotomy was performed: multiple perforations of the terminal ileum and a necrotic gallbladder were found. A right hemicolectomy with 30 cm of the terminal ileum and a cholecystectomy were carried out. At the same time, positive blood cultures for Salmonella typhi were obtained and this confirmed the diagnosis of ileal perforation due to salmonella typhi infection. This case illustrates that Salmonella typhi infection can be a surgical problem in the western countries.

Skeletal muscle metastasis from a conventional renal cell carcinoma, two years after nephrectomy: a case report.

In this paper, we describe a case of skeletal muscle metastasis from a conventional (clear cell) renal cell carcinoma, two years after nephrectomy. Our first clinical tentative diagnosis was soft tissue tumour, showing the mimicking capacity of renal cell carcinoma. A review of literature shows that skeletal muscle metastases from renal cell carcinoma are extremely rare: only 16 cases have been described. In 5/16, the muscle mass was the initial manifestation of the renal tumour. In the other 11/16, the muscle masses were metachronous (10 months-16 years). We conclude that, when confronted with a patient with a muscle mass and a history of renal cell carcinoma, one should always keep in mind the possibility of a (late) renal cell carcinoma metastasis.

Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature.

An athletic 23 year old man presented with suprapubic tenderness, fever, and raised inflammatory blood variables. A diagnostic laparoscopy was performed, with a presumed diagnosis of retrocaecal appendicitis, but no abnormalities were found, apart from free fluid in the pouch of Douglas. Imaging of the pubic area suggested bony infection and inflammation. Biopsy and culture confirmed the presence of Staphylococcus aureus, a very common pathogen. The final diagnosis was osteomyelitis pubis, an infectious disease, and osteitis pubis, an inflammatory disease.

Fasting-induced changes in the expression of genes controlling substrate metabolism in the rat heart.

During fasting, when overall metabolism changes, the contribution of glucose and fatty acids (FA) to cardiac energy production alters as well. Here, we examined if the heart is able to adapt to such fasting-induced changes by modulation of its gene expression. Rats were fed ad libitum or fasted for 46 h, resulting in reduced circulating glucose levels and a 3-fold rise in FA. Besides changes in the cardiac activity or content of proteins involved in glucose or FA metabolism, mRNA levels also altered. The cardiac expression of genes coding for glucose-handling proteins (glucose transporter GLUT4, hexokinase I and II) was up to 70% lower in fasted than in fed rats. In contrast, the mRNA levels of various genes involved in FA transport and metabolism (FA translocase/CD36, muscle-type carnitine palmitoyl transferase 1, long-chain acyl-CoA dehydrogenase) and of the uncoupling protein UCP-3 increased over 50% in hearts of fasted rats. Surprisingly, mRNA levels of the fatty acid- activated transcription factors PPARalpha and PPARbeta/delta were reduced in hearts of fasted rats, whereas in livers, fasting led to a marked rise in PPARalpha mRNA. Reducing FA levels by nicotinic acid administration during the final 8 h of fasting did not affect the expression of the majority of metabolic genes, but totally abolished the induction of UCP-3. In conclusion, the adult rat heart responds to changes in nutritional status, as provoked by 46 h fasting, through adjustment of glucose as well as FA metabolism at the level of gene expression.

Paratuberculosis recognized as a problem at last: a review.

This article attempts to review briefly current opinions on Johne's disease, or paratuberculosis, in ruminants caused by Mycobacterium avium subsp. paratuberculosis. Paratuberculosis has been known to be prevalent in domestic livestock, such as cattle, goats, and sheep, for more than a century. Despite this knowledge only minor efforts have been made to control the disease and, with the attention being focussed on the eradication of other diseases, the problem of paratuberculosis has been neglected in most countries in the past decades. However, recent epidemiological surveys performed in Europe showed a high prevalence of paratuberculosis in cattle and sheep, indicating that the situation has become quite alarming. In addition, the possible role of M. avium subsp. paratuberculosis in the aetiology of Crohn's disease in humans is still debated, as discussed in this article. Therefore, there is suddenly a renewed interest in paratuberculosis, and the disease is recognized as a significant problem. As a consequence, there is a need for reliable diagnostic tools for large-scale use to allow the introduction of programmes to control and eventually eradicate the disease. The current status and the possibilities for such programmes are discussed.

Effects of fatty acids on uncoupling protein-2 expression in the rat heart.

Fatty acids are thought to play a role in the activity of uncoupling proteins (UCP) and have been shown to regulate the expression of genes encoding proteins involved in fatty acid handling. Therefore, we investigated whether fatty acids, which are the main substrates for the heart, affect rat cardiac UCP-2 expression in vivo and in vitro. After birth, when the contribution of fatty acid oxidation to cardiac energy conversion increases, UCP-2 expression enhanced rapidly. In the adult heart, however, UCP-2 mRNA levels did not alter during conditions associated with either enhanced (fasting, diabetes) or decreased (hypertrophy) fatty acid utilization. Exposure of neonatal cardiomyocytes and embryonic rat heart-derived H9c2 cells to fatty acids (palmitic and oleic acid) for 48 h strongly induced UCP-2 expression. Stimulation of neonatal cardiomyocytes with triiodothyronine also increased UCP-2 mRNA levels, though only in the presence of fatty acids. Ligands specific to the fatty acid-activated transcription factor PPARalpha, but not to PPARgamma, acted as inducers of cardiomyocyte UCP-2 expression. It is concluded that fatty acids promote UCP-2 expression in neonatal cardiomyocytes, which might explain the rapid increase in UCP-2 mRNA in the postnatal heart. However, UCP-2 mRNA levels in the adult heart appear to be insensitive to changes in cardiac fatty acid handling under various pathological conditions.