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Laboratory host specificity of 2 biological control agents, already introduced in New Zealand, was compared with actual field parasitism.The parasitoids were Microctonus aethiopoides Loan and Microctonus hyperodae Loan, braconids imported to control the curculionid forage pests Sitona discoideus Gyllenhal and Listronotus bonariensis (Kuschel), respectively. The nontarget weevil species tested included native,introduced, and beneficial species. M. aethiopoides oviposited in 11of the 12 species to which it was exposed and successfully parasitized 9 species. M. hyperodae oviposited in 5 of the 11 species to whichit was exposed and developed successfully in 4 species. Higher percentage parasitism was recorded with M. aethiopoides than with M. hyperodae. Field collections of weevils from Otago, Canterbury, and Waikato indicated that 10 New Zealand natives and 3 other nontarget species, including the weed biological control agent Rhinocyllus conicus (Froehlich), were parasitized by M. aethiopoides. M. hyperodae has been found parasitizing 1 native species, as well as Sitona lepidus Gyllenhal, which was accidentally introduced to New Zealand recently. In nontarget species, parasitism levels in the field of >70% have been recorded for M. aethiopoides and <5% for M. hyperodae. The results of this study suggest that laboratory host range testing is indicative of nontarget parasitism in the field. [ABSTRACT FROM AUTHOR]

The management of aquatic weeds in an irrigation scheme is constrained by the agro-economic system in relation to scheme layout, the nature and ecology of the aquatic weeds, agricultural practice, irrigation and drainage requirements, and the available resources for maintenance. The way in which the ecology, engineering and economics of irrigation and drainage channels interact to produce a pattern of management is investigated for the Mwea Irrigation Settlement Scheme, CentralProvince, Kenya. This is used to develop a simple model which enables the economic implications of varying the aquatic weed management practice to be identified. The model brings the selection of a weed control programme within the principles of engineering economy. [ABSTRACT FROM AUTHOR]

Objective: Many cell types lose responsiveness to anabolic factors during inflammation and disease. Osteogenic Protein 1 (OP1/BMP7) was evaluated for the ability to enhance extracellular matrix synthesis in healthy and OA meniscus cells. Mechanisms of cell response to OP1 were explored., Design: Meniscus and cartilage tissues from healthy tissue donors and osteoarthritis (OA) patients undergoing total knee arthroplasties were acquired. Primary cell cultures were stimulated with OP1 and/or inflammatory factors (IL1α, IL1β, or fibronectin fragments (FnF)) and cellular responses were analyzed by RT-qPCR and immunoblots. Frozen section immunohistochemistry (IHC) was conducted to assess OP1 and receptor proteins in normal and OA meniscus., Results: OP1 treatment of normal meniscus cells resulted in significant, dose-dependent increases in ACAN (aggrecan) and COL2A1, and decreased MMP13 gene transcription, while only ACAN was upregulated (P < 0.01) at the highest dose of OP1 in OA meniscus cells. OP1 induced significantly more ACAN gene transcription in normal meniscus than normal articular cartilage (P = 0.05), and no differences between normal and OA cartilage were detected. Receptor expression and kinetics of canonical signaling activation were similar between normal and OA specimens. Normal meniscus cells treated with inflammatory factors were refractory to OP1 stimulation. Smad1 phosphorylation at an inhibitory site was induced (P = 0.01 for both normal and OA meniscus) by inflammatory cytokine treatment., Conclusions: The meniscus demonstrates resistance to OP1 stimulation in OA and in the presence of inflammatory mediators. MAPK-mediated Smad1 linker phosphorylation is a possible mediator of the loss of anabolic extracellular matrix production in the inflammatory cytokine affected meniscus., (Copyright © 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Objective: Meniscus injury increases osteoarthritis risk but its pathobiology in osteoarthritis is unclear. We hypothesized that older adult vervet monkeys would exhibit knee osteoarthritic changes and the degenerative menisci from these animals would secrete matrix metalloproteinases (MMPs) and pro-inflammatory cytokines that contribute to the development of osteoarthritis., Design: In a cross sectional analysis of healthy young adult (9-12 years) and old (19-26 years) adult female vervet monkeys, knees were evaluated in vivo with computed tomography (CT) imaging, and joint tissues were morphologically graded at necropsy. Meniscus explants were subsequently cultured to evaluate meniscal MMP and cytokine secretion., Results: CT images revealed significant bony osteoarthritic changes in 80% of older monkeys which included increases in osteophyte number and meniscal calcification. Meniscus and cartilage degradation scores were greater in the older monkeys and were positively correlated (r > 0.7). Menisci from older animals exhibiting osteoarthritic changes secreted significantly more MMP-1, MMP-3, and MMP-8 than healthy menisci from younger monkeys. Older menisci without significant osteoarthritic changes secreted more IL-7 than healthy young menisci while older osteoarthritic menisci secreted more IL-7 and granulocyte-macrophage colony-stimulating factor than healthy older menisci., Conclusions: Aged vervets develop naturally occurring knee osteoarthritis that includes involvement of the meniscus. Degenerative menisci secreted markedly increased amounts of matrix-degrading enzymes and inflammatory cytokines. These factors would be expected to act on the meniscus tissue and local joint tissues and may ultimately promote osteoarthritis development. These finding also suggest vervet monkeys are a useful animal model for studying the progression of osteoarthritis., (Copyright © 2015 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Objective: Meniscus injury increases the risk of osteoarthritis; however, the biologic mechanism remains unknown. We hypothesized that pro-inflammatory stimulation of meniscus would increase production of matrix-degrading enzymes, cytokines and chemokines which cause joint tissue destruction and could contribute to osteoarthritis development., Design: Meniscus and cartilage tissue from healthy tissue donors and total knee arthroplasties (TKAs) was cultured. Primary cell cultures were stimulated with pro-inflammatory factors [IL-1β, IL-6, or fibronectin fragments (FnF)] and cellular responses were analyzed by real-time PCR, protein arrays and immunoblots. To determine if NF-κB was required for MMP production, meniscus cultures were treated with inflammatory factors with and without the NF-κB inhibitor, hypoestoxide., Results: Normal and osteoarthritic meniscus cells increased their MMP secretion in response to stimulation, but specific patterns emerged that were unique to each stimulus with the greatest number of MMPs expressed in response to FnF. Meniscus collagen and connective tissue growth factor (CTGF) gene expression was reduced. Expression of cytokines (IL-1α, IL-1β, IL-6), chemokines (IL-8, CXCL1, CXCL2, CSF1) and components of the NF-κB and tumor necrosis factor (TNF) family were significantly increased. Cytokine and chemokine protein production was also increased by stimulation. When primary cell cultures were treated with hypoestoxide in conjunction with pro-inflammatory stimulation, p65 activation was reduced as were MMP-1 and MMP-3 production., Conclusions: Pro-inflammatory stimulation of meniscus cells increased matrix metalloproteinase production and catabolic gene expression. The meniscus could have an active biologic role in osteoarthritis development following joint injury through increased production of cytokines, chemokines, and matrix-degrading enzymes., (Copyright © 2013 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Cryptosporidium is the most common non-viral cause of diarrhea worldwide. Of the 5 described species that contribute to the majority of human infections, C. parvum is of major interest due to its zoonotic potential. A species-specific fluorescence in situ hybridisation probe was designed to the variable region in the small subunit of the 18S rRNA of C. parvum and labeled with Cy3. Probe specificity was validated against a panel of 7 other Cryptosporidium spp. before it was applied to 33 human faecal samples positive for cryptosporidiosis which were obtained during the period from 2006-2007. Results were compared to PCR-RFLP targeting the 18S rDNA. FISH results revealed that 19 of the 33 isolates analysed were identified as C. parvum. Correlation of PCR-RFLP and FISH was statistically significant (P<0.05), resulting in a calculated correlation coefficient of 0.994. In this study, species identification by FISH and PCR-RFLP provided preliminary evidence to support both anthroponotic and zoonotic transmission of sporadic cases of cryptosporidiosis in the Sydney basin. In conclusion, FISH using a C. parvum-specific probe provided an alternative tool for accurate identification of zoonotic Cryptosporidium which will be applied in the future to both epidemiological and outbreak investigations.

Aims: To establish whether germination of Botrytis cinerea was affected by the symbiosis of Bacillus subtilis L-form bacteria with Chinese cabbage., Methods and Results: Germinating seeds of Chinese cabbage were co-cultivated with either L-forms of Bacillus subtilis or 5% (w/v) mannitol by soaking for 3 h. Seeds were then washed in sterile water, sown on a minimal medium and incubated in controlled conditions. L-form symbiosis was detected over a time course by ELISA. Conidial germination of Botrytis cinerea was significantly reduced on cotyledonous leaves of L-form-treated plants compared with controls., Conclusions: Symbiosis of B. subtilis L-form bacteria during seed germination of Chinese cabbage inhibits conidial germination in plants on subsequent exposure to Botrytis cinerea., Significance and Impact of the Study: This is the first account of plant symbiosis with L-form bacteria showing antagonism to a fungal plant pathogen. This has promising implications for the use of this L-form as a biocontrol agent.

PTHrP regulates the rate of chondrocyte differentiation during endochondral bone formation. The expression of PTHrP and its regulation by TGF-beta, BMP-2, and PTHrP was examined in upper sternal chondrocytes following 1, 3, and 5 days of continuous treatment. While TGF-beta stimulated the expression of PTHrP (5-fold), PTHrP caused a slight inhibition, and BMP-2 markedly inhibited PTHrP mRNA expression. The effect of these factors on PTHrP expression was not simply related to the maturational state of the cells, since BMP-2 increased, while both PTHrP and TGF-beta decreased the expression of type X collagen. TGF-beta isoforms 1, 2, and 3 all stimulated PTHrP expression. Signaling events involved in the induction of PTHrP by TGF-beta were further evaluated in a PTHrP-promoter CAT construct. The effect of TGF-beta, BMP-2, and PTHrP on the PTHrP-promoter paralleled their effects on mRNA expression, with TGF-beta significantly increasing CAT activity, BMP-2 decreasing CAT activity, and PTHrP having a minimal effect. Co-transfection of the TGF-beta signaling molecule, Smad 3, mimicked the effect of TGF-beta (induction of PTHrP promoter), while dominant negative Smad 3 inhibited the induction of the PTHrP promoter by TGF-beta. Furthermore, infection with a Smad 3-expressing retrovirus mimicked the effects of exogenously added TGF-beta, and induced PTHrP mRNA expression in the infected chondrocyte culture. In contrast, a dominant negative Smad 3 completely inhibited PTHrP promoter stimulation by TGF-beta, but only partially blocked the effect of TGF-beta on PTHrP mRNA synthesis. These findings demonstrate that PTHrP is expressed in chondrocytes undergoing endochondral ossification, and show regulation, at least in part, by TGF-beta through Smad mediated signaling events., (Copyright 2001 Wiley-Liss, Inc.)

Due to the possibility that bacteria could be involved in the clearance of paralytic shellfish toxins (PST) from bivalve molluscs, investigations into which, if any, bacteria were able to grow at the expense of PST focused on several common shellfish species. These species were blue mussels, oysters, razor fish, cockles, and queen and king scallops. Bacteria associated with these shellfish were isolated on marine agar 2216 and characterized by their carbon utilization profiles (BIOLOG). Selected isolates from groups demonstrating 90% similarity were screened for their ability to metabolize a range of PST (gonyautoxins 1 and 4 [GTX 1/4], GTX 2/3, GTX 5, saxitoxin, and neosaxitoxin) using a novel screening method and confirming its results by high-performance liquid chromatography. Results suggest that molluscan bacteria have different capacities to utilize and transform PST analogues. For example, isolates M12 and R65 were able to reductively transform GTX 1/4 with concomitant production of GTX 2/3, while isolate Q5 apparently degraded GTX 1/4 without the appearance of other GTXs. Other observed possible mechanisms of PST transformations include decarbamoylation by isolate M12 and sulfation of GTXs by isolates Q5, R65, M12, and C3. These findings raise questions as to the possible role of bacteria resident in the shellfish food transport system. Some researchers have suggested that the microflora play a role in supplying nutritional requirements of the host. This study demonstrates that bacteria may also be involved in PST transformation and elimination in molluscan species.

Transforming growth factor-beta (TGF-beta) is a multifunctional regulator of a variety of cellular functions, including proliferation, differentiation, matrix synthesis, and apoptosis. In growth plate chondrocytes, TGF-beta slows the rate of maturation. Because the current paradigm of TGF-beta signaling involves Smad proteins as downstream regulators of target genes, we have characterized their role as mediators of TGF-beta effects on chondrocyte maturation. Both Smad2 and 3 translocated to the nucleus upon TGF-beta1 signaling, but not upon BMP-2 signaling. Cotransfection experiments using the TGF-beta responsive and Smad3 sensitive p3TP-Lux luciferase reporter demonstrated that wild-type Smad3 potentiated, whereas dominant negative Smad3 inhibited TGF-beta1 induced luciferase activity. To confirm the role of Smad2 and 3 as essential mediators of TGF-beta1 effects on chondrocyte maturation, we overexpressed both wild-type and dominant negative Smad2 and 3 in virally infected chondrocyte cultures. Overexpression of both wild-type Smad2 and 3 potentiated the inhibitory effect of TGF-beta on chondrocyte maturation, as determined by colx and alkaline phosphatase activity, whereas dominant negative Smad2 and 3 blocked these effects. Wild-type and dominant negative forms of Smad3 had more pronounced effects than Smad2. Our results define Smad2 and 3 as key mediators of the inhibitory effect of TGF-beta1 signaling on chondrocyte maturation.

Aims: To develop an ELISA for the detection of antigens derived from stable Bacillus subtilis L-form bacteria and to detect these in plants injected with L-form bacteria., Methods and Results: A sandwich ELISA was developed and its specificity was investigated using L-forms and cell-walled forms of B. subtilis, different Bacillus species and a range of bacteria isolated from glasshouse-grown strawberry plants. The detection limits of the ELISA were approximately 10(3) viable cells ml(-1) for L-forms compared with 10(7) viable cells ml(-1) for cell-walled forms. Results showed that L-forms survived and moved within strawberry tissues injected with L-form bacteria., Conclusion: An ELISA that selectively detects B. subtilis L-form bacteria was developed and shown to confirm the presence of L-forms in plants., Significance and Impact of the Study: This will be a valuable rapid method to further studies on L-form plant interactions.

The formation of bone is a continual process in vertebrate development, initiated during fetal development and persisting in adulthood in the form of remodeling and repair. The remarkable capacity of skeletal tissues to regenerate has led to the hypothesis that the molecular signaling pathways regulating skeletogenesis are shared during fetal development and adult wound healing. A number of key regulatory pathways that are required for endochondral ossification during fetal development are described, and their reintroduction in fracture repair demonstrated. Secreted proteins such as Sonic and Indian hedgehog exert their effect on pattern formation and chondrogenesis in the appendicular skeleton, partly through regulation of molecules such as bone morphogenic proteins (Bmps) and parathyroid hormone-related peptide (PTHrP). Once chondrocytes have matured and hypertrophied, they undergo apoptosis and are replaced by bone; the transcription factor Cbfal plays a critical role in this process of chondrocyte differentiation and ossification. Analyses of the expression patterns of these genes during fracture healing strongly suggest that they play equivalent roles in adult wound repair. Knowledge acquired through the study of fetal skeletogenesis will undoubtedly contribute to an understanding of fracture repair, and subsequently guide the development of biologically based therapeutic interventions.

Objective: To evaluate the effectiveness of laparoscopic common bile duct exploration in unselected patients., Design: Consecutive sample., Setting: Tertiary care general hospital., Patients: Three hundred and two patients with symptomatic cholelithiasis presenting to a single surgeon during a 5-year period., Interventions: Laparoscopic cholecystectomy, cholangiography, and common bile duct exploration., Main Outcome Measures: Successful laparoscopic cholecystectomy and common bile duct exploration., Results: Three hundred and two consecutive patients underwent cholecystectomy for symptomatic cholelithiasis; 280 of the procedures were successfully completed laparoscopically. Cholangiography was attempted in 269 patients, was successful in 239, and revealed evidence of choledocholithiasis in 25. Preoperative ultrasonography and liver function tests predicted the presence of common bile duct stones in 24% and 32% of patients, respectively. Seven of the patients with choledocholithiasis presented with biliary colic, 7 with biliary colic and jaundice, 8 with acute cholecystitis (3 with gallbladder perforation), 1 with acute cholecystitis and jaundice, and 2 with gallstone pancreatitis. Four of 5 patients underwent successful transcystic exploration with a biliary Fogarty catheter, 12 of 16 patients underwent successful transcystic choledochoscopy and stone basket extraction, and all 4 attempts at choledochotomy and choledochoscopic stone basket extraction were successful, for a total success rate of 80% with laparoscopic common bile duct exploration. One of the failures was converted to an open procedure, and 4 of the failures had successful postoperative endoscopic retrograde cholangiopancreatography and extraction of stones., Conclusions: Laparoscopic cholecystectomy and common bile duct exploration is a highly successful procedure for the management of common duct stones in an unselected group of patients. Choledochotomy with choledochoscopy is the preferred method of common bile duct exploration.

In an effort to explore the utility of classic Nissen fundoplication performed laparoscopically, 16 adult patients with well documented gastroesophageal reflux underwent laparoscopic Nissen fundoplication. A full gastric fundal dissection was performed, with division of at least 2 short gastric vessels. The crura were approximated with 1-3 sutures, and a loose fundoplication was performed over an esophageal dilator (minimum 46 F) with three stitches, encompassing the esophageal wall (2.5 cm in length). All patients had symptoms of reflux refractory to medical therapy, and four had an esophageal stricture requiring preoperative dilatation. Fifteen of 16 procedures were completed laparoscopically; one patient required conversion to an open procedure to control bleeding from a posterior gastric vein. There were no other operative complications. The average operative time was 180 minutes (range 120-285). Clear liquids were begun at the passage of flatus (average 2.7 days postop), and patients were discharged an average of 4.1 days postoperatively. Postoperative complications included ileus (1 patient for 6 days), severe subcutaneous emphysema (1 patient), and dysphagia requiring dilatation (5 patients). In short follow-up (mean 4.43 mo., range 1-12 mo.) 14 of 15 patients had complete abolition of reflux symptoms, but one patient with persistent heartburn had reflux demonstrated on a postoperative upper GI series. Thirteen of 16 patients returned to full function within 14 days of surgery. We conclude that standard Nissen fundoplication is possible laparoscopically, and allows a rapid recovery from surgery. However, it is difficult, time consuming, and associated with a significant rate of recurrence in the short term (6%).(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To review the relationship between tumor thickness and the subsequent development of cervical nodal metastases in 26 patients with stage I and II carcinomas of the oral tongue., Methods: The histologic features of 26 consecutive patients treated for squamous carcinoma of the oral tongue were reviewed "blindly" by a pathologist, and the variables were correlated with clinical outcome., Results: No association between tumor thickness and nodal metastases was found. Perineural infiltration was the only factor to approach statistical significance. There was also no statistically significant correlation between tumor thickness and patient survival., Conclusions: The histologic factors considered herein probably should be controlled for when comparing results of treatment of cancer of the oral tongue.

Bile duct injury is an unusual complication of laparoscopic cholecystectomy. Although the exact incidence is yet to be determined, it does appear to be more common than bile duct injury during open cholecystectomy. Previous publications have attempted to document the incidence of bile duct injuries and methods to prevent it. We reviewed our experience with 11 bile duct injuries from laparoscopic cholecystectomy. Such injuries were manifested by abdominal pain, low-grade fever, and hyperbilirubinemia or biliary fistula. These patients' injuries were treated by using drainage or reexploration and ligation of cystic duct and subcholecystic duct leaks and Roux-en-Y hepaticojejunostomy for common duct strictures and lacerations.

Hepatic resection of metastatic colorectal carcinoma is widely advocated with 5-year survival rates quoted at 20 to 25 per cent. However, concerns about the morbidity and mortality for this procedure still exist. It is estimated that only 25 per cent of patients potentially eligible for hepatic resection are actually referred for evaluation, possibly secondary to concerns about the morbidity and mortality of the surgical procedure involved. All patients undergoing such resections at the Emory University Affiliated Hospitals between January 1, 1984 and December 31, 1989 were reviewed to determine the associated morbidity and mortality. Forty-three patients were identified (23 men, 20 women, ranging in age from 32 to 80 years (mean of 60.8). The average postoperative intensive care unit (ICU) stay was 3.2 days (range 1 to 12) and the average hospital stay was 15 days (range 6 to 45). There were no postoperative deaths, and 10 patients (23%) developed significant complications (1 biliary fistula, 2 thrombophlebitis, 3 abscess/wound infections, 1 hepatic insufficiency, 1 pneumothorax, 1 pleural effusion, 1 lobar pulmonary collapse). The occurrence of complications was not related to preoperative liver enzymes, absolute tumor mass present, or associated co-morbid disease. The extent of liver resection, length of operation, and number of units of blood transfused were all correlated with the occurrence of complications (P = 0.01, 0.01, and 0.05, respectively). Likewise, the length of hospital stay and ICU stay were directly related to the extent of hepatic resection (P = 0.05 and 0.09) and number of transfusions (P = 0.05 and 0.01). The length of operation showed such a trend but was not statistically significant (P = 0.2).(ABSTRACT TRUNCATED AT 250 WORDS)

Though laparoscopic cholecystectomy has become widespread, questions remain as to its success rate, its role in acute cholecystitis, the role of cholangiography, and whether laser use is necessary. To attempt to answer these questions, the first 100 patients undergoing laparoscopic cholecystectomy at Emory University using electrosurgical diathermy were reviewed. Patients underwent cholecystectomy for biliary colic (87), gallstone pancreatitis (1), and acute cholecystitis (12). The average length of hospital stay was 29 hours (range: 12 hours to 5 days). Laparoscopic cholecystectomy was not possible in 7 patients because of gangrenous cholecystitis (2), adhesions from previous surgery (2), equipment failure (2), and choledochoduodenal fistula found at surgery (1). Two patients developed bile leaks from accessory bile ducts that healed spontaneously. There were no other complications. The average time required to complete the laparoscopic cholecystectomy was 115 minutes (range: 45 to 238 minutes) and was not significantly different in those patients undergoing intraoperative cholangiography (117 minutes) versus those without (109 minutes). Common duct stones were uncommon in this series. Thirty-three patients underwent intraoperative cholangiogram. One patient was found to have a common duct stone, which was pushed into the duodenum using a Fogarty catheter (American Edwards Laboratories; Anasco, Puerto Rico) inserted through the cystic duct at the time of laparoscopic cholecystectomy. Twelve patients with acute cholecystitis underwent an attempt at laparoscopic cholecystectomy that was successful in nine. These procedures were difficult and lengthy (mean of 143 minutes). Causes for failure were gangrenous cholecystitis (2) and equipment failure (1). In conclusion, laparoscopic cholecystectomy can be performed with a high success rate (93%) and low morbidity (2%). No complications seemed attributable to electrosurgical dissection.

The ileal pouch-anal anastomosis has become a practical alternative to proctocolectomy for the treatment of ulcerative colitis and polyposis coli. To evaluate its success, the Emory University Affiliated Hospital experience from February 1984 to March 1989 was retrospectively reviewed. There were a total of 50 patients identified; 84 per cent had ulcerative colitis, and 16 per cent had polyposis coli (familial polyposis and Gardner's syndrome). The majority of these patients underwent a two-stage operation, but one-third required a three-stage procedure due to difficulty in mucosal proctectomy or toxic megacolon. J-pouch construction was performed in 72 per cent of patients, S-pouch construction in 14 per cent, straight ileo-anal anastomosis in 8 per cent, and lateral isoperistaltic ileo-anal anastomosis in 6 per cent. Of the 50 patients, 36 (72%) have had closure of the temporary ileostomy. Fourteen patients have not had ileostomy closure due to change in diagnosis to Crohn's disease, operative complications, or ileostomy closure pending. The combined operative morbidity per patient for the ileal pouch-anal anastomosis and the closure of the ileostomy was 32 per cent. This included bowel obstruction, 16 per cent; pelvic abscess, 6 per cent; and ileo-anal separation, 4 per cent. Follow-up on patients with ileostomy closure ranged from 6 months to 4 years (mean, 1.3 years). Stool frequency was 5.9 stools per 24 hours at 6 months and improved with time. During the follow-up period, all patients were eventually completely continent of stool during the day, and most became completely continent of stool at night.(ABSTRACT TRUNCATED AT 250 WORDS)

Numerous case reports suggest that diversion of the fecal stream results in nonspecific colitis, with abnormalities ranging from minimal friability to gross ulceration. Published reports consist largely of patients with symptomatic colitis, and there are scant data suggesting at what frequency diversion colitis actually occurs. In an attempt to identify the frequency of diversion colitis and any associated etiologic factors, 20 patients scheduled for colostomy closure at Grady Memorial Hospital between 8/1/88 and 6/15/89 underwent colonoscopy, including the excluded segment, to evaluate for diversion colitis. Colostomies were performed for the management of diverticulitis, trauma, cancer, protection of an anastomosis, and diversion of fecal fistula. Patients with ulcerative colitis or Crohn's disease were excluded. The colon was classified grossly as normal or colitis (including easy friability, edema, inflammation, and ulceration as colitis). Fourteen of the 20 patients (70%) had findings of diversion colitis (DC), while six had a normal exam (NL). Nine biopsies were performed in the DC group and all revealed microscopic abnormalities. One of the normal patients was also biopsied, revealing mild, nonspecific changes. There was no difference in mean age (DC 49.3, NL 48.2), interval from formation of colostomy (DC 9.21 +/- 7.27 months, NL 2.83 +/- 1.94 months), type of colostomy, or reason for colostomy in the two groups. None of the DC patients had symptoms of colitis (mucous or bloody discharge, tenesmus, or pain), and one of the DC patients manifested symptoms of colitis after colostomy closure. We conclude that diversion colitis is a common subclinical problem in patients with a diverting colostomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Controversy exists in the local treatment of early stage breast cancer. In an effort to determine what criteria are used in selection of therapy for patients with breast cancer, we reviewed the experience of early stage breast cancer at Crawford Long Hospital of Emory University during 1986 and 1987. One hundred eighty-three patients were identified with Stage 0, I, or II breast cancer. A total of 11% of patients were treated by lumpectomy and radiotherapy. Residence distant from the hospital was associated with a low rate of utilization of lumpectomy and radiotherapy (p = .05). The strongest predictor of therapy was the surgeon involved in the patient's care (p = 0.001). For surgeons who cared for five or more patients with breast cancer over this time period, rates of utilization of lumpectomy and radiotherapy ranged from 0 to 20% of patients. The results of this study suggest that the surgeon consulted is the major determinant of the type of therapy used in the primary management of breast cancer.

Following abdominoperineal resection, the empty space of the pelvic hollow is filled by loops of small intestine, which may become fixed and cause obstruction. In patients who require adjuvant radiotherapy, such loops of intestine fixed in the pelvis may predispose the patient to radiation enteritis. Proposed methods to prevent such fixed loops of small intestine in the pelvis include closure of the pelvic peritoneum with subperitoneal drainage, fixation of the bladder to the sacrum, retroversion of the uterus, placement of prosthetic mesh, and placement of an omental pedicle graft in the pelvic hollow. The omental pedicle graft has the advantages of ease of performance, use of autologous tissue, and filling the pelvic hollow with vascularized tissue, which should decrease the risk of postoperative pelvic abscess. This study reviews the technique of omental pedicle graft closure of the pelvis and the results of it in our initial eight patients. The omental pedicle graft has become the preferred method of pelvic reconstruction following abdominoperineal resection at Grady Memorial Hospital, Atlanta, Georgia.

Choledocholithiasis may be managed by surgical extraction of stones or endoscopic papillotomy with extraction of stones. To evaluate these methods of management, the charts of all patients with choledocholithiasis admitted to Crawford Long Hospital of Emory University between April 1, 1983, and April 30, 1988, were reviewed. One hundred patients were identified; 42 were treated by common bile duct exploration (CBDE) and 58 had endoscopic papillotomy with extraction of stones (EP) as their initial treatment. The two groups were similar in regards to age, but the CBDE group had more comorbid conditions (average 2.5/patient in CBDE vs 1.8/patient in EP) and a higher incidence of acute cholecystitis and/or cholangitis (74% of CBDE patients; 24% of EP patients). Successful extraction of all stones occurred in 79 per cent of CBDE patients and 90 per cent of EP patients. Of those patients with retained stones following CBDE, all were later extracted by EP. Of patients having EP as their initial procedure, 24 per cent required repeat endoscopic procedures for extraction of residual stones and only six patients (10.4%) required CBDE for retained stones. Morbidity was lower (10% vs 23%) and hospital stay shorter (3.6 days vs 10.4 days) in the EP than CBDE patients; thus, the two groups are not completely comparable. Mortality was similar in the two groups (1.7% EP, 2.3% CBDE).

To better define the risk of breast cancer in young patients, a retrospective review of all breast biopsies in women under age 40 years at Grady Memorial Hospital, Atlanta, from Dec 1, 1981, to Aug 15, 1987, was performed. During this time, 751 biopsies were performed on patients aged 9 to 40 years. None of the 128 patients aged 20 years or less had carcinoma. Of 150 patients aged 21 to 25 years, two had carcinoma. At age 26, there began a steady rise in the incidence of carcinoma, such that in the 36- to 40-year age group, carcinoma was present in 24.4% of the specimens. This retrospective review confirms previous reports that suggest that carcinoma of the breast is distinctly unusual in patients under age 20 and that breast masses in these young patients should be managed conservatively. As the incidence of carcinoma increases with the age of the patient, one's threshold for excisional biopsy should decrease.

Perianal infections in patients with acute leukemia and granulocytopenia are potentially lethal conditions. To evaluate the management of perianal infections in patients with granulocytopenia and acute leukemia, all such patients treated at Emory University Hospital between January 1, 1980, and December 31, 1985, were reviewed. Twenty patients were found to have severe granulocytopenia (fewer than 500 polymorphonuclear leukocytes/mm3) and perianal infection, representing 5.7 per cent of all hematology service admissions during that period. Eleven patients were managed conservatively with broad-spectrum antibiotics and supportive measures, and nine patients underwent operative drainage of the perianal infection in addition to conservative measures. The two groups were similar in respect to age, associated conditions, length of hospitalization, and degree of perianal infection, with the exception that operatively drained patients were more likely to have positive blood cultures (7/9 operatively drained; 4/11 conservatively managed). Mortality was higher in the operatively drained group (44.4% vs 9% in the conservatively managed), and three patients had progression of the local infection after drainage, two of whom required a diverting colostomy. The overall mortality attributed to perianal disease in these severely granulocytopenic patients was 25 per cent. From this review, operative drainage of perianal infection does not appear to increase survival or decrease morbidity in patients with severe granulocytopenia.

Needle aspiration cytology has been reported to be a highly sensitive and specific method of evaluation of solid breast masses when used by a single individual or closely knit group of clinicians and cytopathologists. This report summarizes the experience in 86 patients in whom needle aspiration cytology and excisional biopsy of solid breast masses were performed. All clinical evaluations, including needle aspirations and excisional biopsies, were performed by surgical residents in the Breast Clinic of Grady Memorial Hospital. The cytologic and histologic interpretations were performed by members of the Department of Pathology without direct interaction with the patients. Of the entire group of 86 patients, 27 had cancer and 59 had benign breast disease. There were no false-positive findings and five (11.9%) false-negative findings. The sensitivity of fine-needle aspiration was 73.7 per cent and specificity 100 per cent. The results are compatible with previously reported studies and it is believed that needle aspiration cytology is an integral part of evaluation of breast masses.

To assess the role of the general surgeon in the care of patients with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC) the hospital records of all patients with AIDS or ARC who underwent a major operation at the General Surgical Service of Crawford W. Long Memorial Hospital were reviewed. Of 79 patients with AIDS or ARC diagnosed since 1982, 14 required major abdominal surgery. Operations performed were for gastrointestinal (GI) complications of opportunistic infections and neoplasms (four), diagnosis of major retroperitoneal lymphadenopathy (four), and treatment of AIDS-related immune thrombocytopenia (six). GI complications consisted of two cases of cytomegalovirus perforation of ileum and colon, one case of bleeding ileocolonic lymphoma, and one case of cryptosporidium cholecystitis. Laparotomy for diagnosis of retroperitoneal lymphadenopathy was performed in four patients and provided diagnostic material in three of them. Six patients underwent splenectomy for AIDS-related immune thrombocytopenia. Four of these patients had previously been treated with prednisone without impressive results. All patients had marked improvement of their platelet counts and clinical bleeding after splenectomy. Postoperative complications were common and consisted of wound infection, disseminated intravascular coagulation, GI bleeding, pneumocystis pneumonia, small-bowel obstruction, and cytomegalovirus pneumonia. One patient died after laparotomy for perforated ulcers of the ileum and colon.

This study reviews the recent experience with popliteal artery injuries at the Massachusetts General Hospital. Twenty-two patients suffered 24 injuries. The overall limb salvage was 83%. Blunt trauma accounted for 19 of the cases and was associated with femur fractures, knee dislocations, and tibia-fibular and plateau fractures: four amputations (21%) resulted. There were five penetrating injuries from three gunshot wounds, one stab wound, and one laceration: no amputations occurred. The major factor in the amputated limbs was delay in diagnosis and therapy of the arterial injury associated with blunt trauma. Arterial disruption secondary to penetrating injuries was recognized more quickly and had a better outcome. A higher index of suspicion in blunt trauma may improve results. Recommendations for therapy are: arterial reconstruction should generally precede orthopedic operation. Venous ligation was not associated with increased limb loss, but we recommend repair if possible. Arterial repair includes thrombo-embolectomy in distal arteries. If necessary, reverse saphenous vein is grafted. When operation is unsuccessful, revision should be performed.

A technique of esophagogastric anastomosis using the end-to-end anastamotic (EEA) stapler following esophagectomy is described in detail. Twenty-two patients underwent esophagectomy for carcinoma at various levels. There were no anastomotic leaks and no operative mortalities. Complications included wound infection (3), pneumonia (1), and late stricture (2). The strictures resulted from use of the small (25-mm) cartridge and responded to dilatation. Technical details of the technique include complete division of the esophagus before inserting the stapler, use of the pursestring instrument, use of "guy" sutures to aid in introduction of the anvil, and use of a proximal esophageal "traction clamp" to avoid tearing the esophagus. The 31-mm cartridge is used whenever possible. It is concluded that EEA is a very safe method of esophagogastrostomy when used with strict attention to technical details.

Three cases of benign duodenocolic fistula are presented, and the diagnosis and treatment reviewed. Patients with benign duodenocolic fistulas usually complain of diarrhea, and occasionally nausea and feculent vomiting. Physical examinations are nonspecific, revealing wasting from the chronic diarrhea. Barium enemas are usually diagnostic. Therapy consists of excision of the fistula and repair of the duodenal and colonic defects.

From 1 January 1984 to 31 August 1987, 11 patients underwent splenectomy for treatment of thrombocytopenia related to human immunodeficiency virus (HIV). Six of the patients had been previously treated with prednisone, five of whom showed some response. None of those who responded to the prednisone had a sustained response and, thus, all required splenectomy. All 11 patients had an excellent response to splenectomy. The average preoperative and postoperative platelet counts were 19,700 and 498,000, respectively. All patients have maintained normal platelet counts at an average follow-up period of 12.4 months (range of one to 37 months). There were no postoperative deaths. Morbidity was minimal; in two patients, wound seromas developed. In one patient, acquired immunodeficiency syndrome (AIDS) developed 12 months after splenectomy, but none of the other patients have evidence of AIDS. Splenectomy is a safe and effective therapy for HIV-related immune thrombocytopenia.