Paoli Hospital

Video-assisted anal fistula treatment (VAAFT) is a novel minimally invasive and sphincter-saving technique for treating complex fistulas. The aim of this report is to describe the procedural steps and preliminary results of VAAFT. Karl Storz Video Equipment is used. Key steps are visualization of the fistula tract using the fistuloscope, correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening using a stapler or cutaneous-mucosal flap. Diagnostic fistuloscopy under irrigation is followed by an operative phase of fulguration of the fistula tract, closure of the internal opening and suture reinforcement with cyanoacrylate. From May 2006 to May 2011, we operated on 136 patients using VAAFT. Ninety-eight patients were followed up for a minimum of 6 months. No major complications occurred. In most cases, both short-term and long-term postoperative pain was acceptable. Primary healing was achieved in 72 patients (73.5%) within 2–3 months of the operation. Sixty-two patients were followed up for more than 1 year. The percentage of the patients healed after 1 year was 87.1%. The main feature of the VAAFT technique is that the procedure is performed entirely under direct endoluminal vision. With this approach, the internal opening can be found in 82.6% of cases. Moreover, fistuloscopy helps to identify any possible secondary tracts or chronic abscesses. The VAAFT technique is sphincter-saving, and the surgical wounds are extremely small. Our preliminary results are very promising.

The thermal J-V characteristic for a tunnel junction is derived in terms of a generalized theory. The resulting functional form of the equations is similar to that of Stratton; however, in the present formulation, the physical parameters of the junction appear explicitly, and their effect upon the thermal characteristic is readily appreciated. In Stratton's work, the physical constants appear in the integrand of integral that can be solved only numerically. The theory is applied to symmetric and asymmetric junctions. For the symmetric case, it is shown that, at a given temperature, the percentage change Ĵ in the high-temperature thermal component of current from the low-temperature value increases initially with increasing voltage bias up to a maximum peak, and thereafter decreases rapidly. The voltage bias at which the component of thermal current maxima occurs is equal to the interfacial barrier height and, as such, permits what is probably the most accurate method of barrier height determination. Similar results are obtained for the asymmetric barrier; however, in this case, Ĵ depends upon the polarity of the voltage bias for V>φ1, and two Ĵ maxima occur at voltages corresponding to the two distinct interfacial barrier heights φ1 and φ2.

STUDY DESIGN: A retrospective analysis of graft and plate complications after multilevel anterior cervical corpectomy and fusion (ACF) attributed to spondylosis, stenosis, and ossification of posterior longitudinal ligament was conducted. OBJECTIVE: To identify factors contributing to graft and plate complications in this population. SUMMARY OF BACKGROUND DATA: Biomechanical factors contributing to the increased morbidity associated with plated multilevel ACF were evaluated. METHODS: Graft- and/or plate-related complications were retrospectively reviewed in 33 patients undergoing two-level ACF reconstructions and in seven patients having three-level ACF reconstructions performed with iliac crest grafting and instrumentation with a fixed-plated design (cervical spine locking plate). Neurologic status was assessed before surgery and after surgery using both the Nurick Grading Scale and modified JOA (Japanese Orthopaedic Association) Score. The patients were observed an average of 31.4 months after surgery. The follow-up included lateral flexion and extension radiographs and a neurologic examination. RESULTS: Two of the 33 patients undergoing two-level fusions available for long-term follow-up after surgery developed reconstruction failures. All of the remaining fusions were successful, demonstrated by lateral flexion and extension radiographs. Seven patients had plated three-level corpectomy reconstructions. Five of the seven who had anterior-only reconstruction failed. DISCUSSION: A two-level ACF reconstruction is reliable with an anterior strut graft and fixed screw plate construct. A three-level ACF reconstruction is not reliably achieved with an anterior-only construct. The construct failures may be attributed in part to the fixed-plated design being used, as well as the long lever arm of the construct. CONCLUSION: There is a 6% failure rate after fixed-plated (cervical spine locking plate) two-level ACF reconstruction but a 71% failure rate after three-level fixed-plated ACF reconstruction. Future consideration should be given to simultaneous posterior fusion.

The INHAND Project (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions in Rats and Mice) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP), and North America (STP) to develop an internationally accepted nomenclature for proliferative and nonproliferative lesions in laboratory animals. The purpose of this publication is to provide a standardized nomenclature and differential diagnosis for classifying microscopic lesions observed in the male reproductive system of laboratory rats and mice, with color microphotographs illustrating examples of some lesions. The standardized nomenclature presented in this document is also available for society members electronically on the Internet (http://goreni.org). Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous and aging lesions as well as lesions induced by exposure to test materials. A widely accepted and utilized international harmonization of nomenclature for lesions of the male reproductive system in laboratory animals will decrease confusion among regulatory and scientific research organizations in different countries and provide a common language to increase and enrich international exchanges of information among toxicologists and pathologists.

This paper discusses in detail the shape of the potential barrier existing between two parallel-plane metal electrodes separated by a thin insulating film. The emission-limited current flow between the electrodes is determined for symmetric and asymmetric junctions. The asymmetric J-V (current-voltage) characteristic is of particular interest, as it can be shown that the difference in work function of the two electrodes comprising the junction can be obtained from a perfunctory study of the characteristic. The thermionic J-V characteristic is compared to the tunnel J-V characteristic. For a temperature of 300°K, and for a barrier thickness less than 40 Å, the tunnel J-V characteristic predominates. However, for barrier thickness greater than 40 Å, either the thermionic or the tunnel characteristic can predominate, depending upon the barrier height and the applied voltage. In the case of asymmetric junctions, there may be a reversal of direction of rectification with decreasing temperature. This reversal of rectification may explain the similar effect sometimes observed in tunnel junctions.

The frequency and severity of cardiac arrhythmias were studied in 70 patients with spontaneous subarachnoid hemorrhage investigated prospectively with 24-hour Holter monitoring. Patients were less than 70 years old and without clinical and/or ECG signs of previous heart disease; Holter monitoring was initiated within 48 hours of subarachnoid hemorrhage. Arrhythmias were detected in 64 of the 70 patients (91%). Twenty-nine of the 70 patients (41%) showed serious cardiac arrhythmias; malignant ventricular arrhythmias, i.e., torsade de pointe and ventricular flutter or fibrillation, occurred in 3 cases. Serious ventricular arrhythmias were associated with QTc prolongation and hypokalemia. No correlation was found between the frequency and severity of cardiac arrhythmias and the neurologic condition, the site and extent of intracranial blood on computed tomography scan, or the location of ruptured malformation. The extremely high incidence of cardiac arrhythmias, sometimes serious, in the acute period after subarachnoid hemorrhage and the absence of clinical and radiologic predictors make systematic continuous ECG monitoring compulsory to improve the overall results of subarachnoid hemorrhage, irrespective of early or delayed surgical treatment.

A prospective cardiologic evaluation was performed in 83 consecutive patients with transient cerebral ischemia or mild stroke and without symptoms or electrocardiographic signs of ischemic heart disease. Patients were studied with an electrocardiographic exercise test; a positive test was followed by exercise Thallium-201 myocardial scintigraphy. Results were compared to those obtained in a group of 83 age and sex-matched healthy subjects submitted to the same study protocol. Asymptomatic coronary artery disease was detected in 28% of cerebrovascular patients with adequate electrocardiographic exercise test. A scintigraphic perfusion defect of variable extension was found in 19 of them. In the control group the electrocardiographic exercise test was positive in only 6% (p less than 0.01). Our results support the concept that: asymptomatic ischemic heart disease is often associated with cerebrovascular disease; therefore cerebral ischemic attacks may be a marker of coronary artery disease, an active investigation of the heart should be considered in cerebrovascular patients in order to plan optimal, comprehensive management.

Autogenous block bone grafts have been highly successful in treating human periodontal defects, restoring esthetics, and developing adequate bone volume for dental implant placement. Limitations in available donor bone, the need for an added surgical procedure, and other potential complications have made the use of allogenic bone graft materials an important alternative. One patient described in this report presented with fractured root syndrome of the right maxillary incisor with severe resorption of the buccal plate. After atraumatic tooth extraction, a staged treatment approach involving localized ridge augmentation with an allogenic iliac bone block material and dental implant placement was used. The host bone completely incorporated the graft with only minor resorption, which enabled the implant to be placed. The allogenic bone block material used in this study was an effective alternative to harvesting and grafting autogenous bone for implant site development. The cases presented in this article clinically demonstrate the efficacy of using a block allograft in generating effective new bone fill for dental implant placement.

An increasing number of criminal cases have claimed the defendant to be in a state of sleepwalking or related disorders induced by high quantities of alcohol. Sleepwalkers who commit violent acts, sexual assaults and other criminal acts are thought to be in a state of automatism, lacking conscious awareness and criminal intent. They may be acquitted in criminal trials. On the other hand, criminal acts performed as the result of voluntary alcohol intoxication alone cannot be used as a complete defense. The alcohol-induced sleepwalking criminal defense is most often based on past clinical or legal reports that ingestion of alcohol directly 'triggers' sleepwalking or increased the risk of sleepwalking by increasing the quantity of slow wave sleep (SWS). A review of the sleep medicine literature found no sleep laboratory studies of the effects of alcohol on the sleep of clinically diagnosed sleepwalkers. However, 19 sleep laboratory studies of the effects of alcohol on the sleep of healthy non-drinkers or social drinkers were identified with none reporting a change in SWS as a percentage of total sleep time. However, in six of 19 studies, a modest but statistically significant increase in SWS was found in the first 2-4 h. Among studies of sleep in alcohol abusers and abstinent abusers, the quantity and percentage of SWS was most often reduced and sometimes absent. Claims that direct alcohol provocation tests can assist in the forensic assessment of these cases found no support of any kind in the medical literature with not a single report of testing in normative or patient groups and no reports of validation testing of any sort. There is no direct experimental evidence that alcohol predisposes or triggers sleepwalking or related disorders. A legal defense of sleepwalking resulting from voluntarily ingested alcohol should be consistent with the current state of art sleep science and meet generally accepted requirements for the diagnosis of sleepwalking and other parasomnias.

STUDY OBJECTIVES: To review medical and legal case reports to determine how many appear to support the belief that violence against other individuals that occurs during Disorders of Arousal - sleepwalking, confusional arousal, and sleep terrors - is triggered by direct physical contact or close proximity to that individual and does not occur randomly or spontaneously. DESIGN: Historical review of case reports in the medical and legal literature. MEASUREMENTS AND RESULTS: A total of 32 cases drawn from medical and legal literature were reviewed. Each case contained a record of violence associated with Disorders of Arousal; in each, details of the violent behavior were available. Violent behaviors associated with provocations and/or close proximity were found to be present in 100% of confusional arousal patients and 81% of sleep terror patients. Violent behaviors were associated with provocation or close proximity in 40%-90% of sleepwalking cases, depending on whether the legal verdict and other factors were taken into account. Often the provocation was quite minor and the response greatly exaggerated. The specific manner in which the violence was triggered differed among sleepwalking, confusional arousals, and sleep terrors. CONCLUSIONS: In the cases reviewed, violent behavior directed against other individuals associated with Disorders of Arousal most frequently appeared to follow direct provocation by, or close proximity to, another individual. Sleepwalkers most often did not seek out victims, but rather the victims sought out or encountered the sleepwalker. These conclusions are tempered by several limitations: the selection of cases was not random and may not represent an accurate sample of violent behaviors associated with Disorders of Arousal. Also, final verdicts by juries in reported legal cases should not be confused with scientific proof of the presence or absence of sleepwalking. The pathophysiology of Disorders of Arousal with and without violent behavior could be associated with normally occurring deactivation of the frontal lobes during slow wave sleep (SWS) connected via atypically active thalamocortical pathways to the limbic areas. It is not known if the violent sleepwalker, confusional arousal patient, or sleep terror patient differs from other patients with these disorders. The conclusions of this case series await confirmation by the results of future sleep laboratory based studies.

STUDY OBJECTIVES: We tested whether providing adults with obstructive sleep apnea (OSA) with daily Web-based access to their positive airway pressure (PAP) usage over 3 mo with or without a financial incentive in the first week improves adherence and functional outcomes. SETTING: Academic- and community-based sleep centers. PARTICIPANTS: One hundred thirty-eight adults with newly diagnosed OSA starting PAP treatment. INTERVENTIONS: Participants were randomized to: usual care, usual care with access to PAP usage, or usual care with access to PAP usage and a financial incentive. PAP data were transmitted daily by wireless modem from the participants' PAP unit to a website where hours of usage were displayed. Participants in the financial incentive group could earn up to $30/day in the first week for objective PAP use ≥ 4 h/day. MEASUREMENTS AND RESULTS: Mean hours of daily PAP use in the two groups with access to PAP usage data did not differ from each other but was significantly greater than that in the usual care group in the first week and over 3 mo (P < 0.0001). Average daily use (mean ± standard deviation) during the first week of PAP intervention was 4.7 ± 3.3 h in the usual care group, and 5.9 ± 2.5 h and 6.3 ± 2.5 h in the Web access groups with and without financial incentive respectively. Adherence over the 3-mo intervention decreased at a relatively constant rate in all three groups. Functional Outcomes of Sleep Questionnaire change scores at 3 mo improved within each group (P < 0.0001) but change scores of the two groups with Web access to PAP data were not different than those in the control group (P > 0.124). CONCLUSIONS: Positive airway pressure adherence is significantly improved by giving patients Web access to information about their use of the treatment. Inclusion of a financial incentive in the first week had no additive effect in improving adherence.

Most patients with serum hepatitis C virus (HCV) RNA and persistently normal alanine transaminase (ALT) levels show histological features of mild to moderately active chronic hepatitis. Some cirrhosis has also been reported. To assess whether interferon (IFN) treatment led to long-term HCV suppression in these patients, 31 previously untreated patients (15 men, 16 women; mean age, 44 years) with serum HCV RNA, persistently normal ALT levels on at least four consecutive occasions 2 months apart, and histological features of chronic hepatitis (21 mild activity, 10 moderate activity) were randomized to receive 1FN-alpha-2a, 3 MU three times a week for 6 months (n = 16), or no treatment (n = 15). All patients were followed up for at least 6 months after treatment ended. HCV RNA was tested by nested reverse-transcription polymerase chain reaction (RT-PCR) using 5'-untranslated region complementary primers, quantified by branched-DNA assay, and typed by nested RT-PCR testing for the HCV core region. Treated and untreated patients had similar epidemiological, virological, and histological characteristics. At the end of treatment, serum HCV RNA was still detected in 15 patients (94%) and 14 controls (93%). ALT levels flared up in 10 patients receiving IFN (62%) and in 1 control (62% vs. 7%; P < .005, chi2 test). In conclusion, 6 months' treatment with IFN-alpha-2a did not eradicate HCV RNA from serum in carriers with persistently normal ALT levels but caused ALT flare-ups in two thirds of them. Until more is known about the natural history of HCV RNA carriers with normal ALT levels, these patients should not be treated with IFN.

One hundred and eighty thousand new cases of invasive breast cancer were diagnosed in 1992 within the United States. This disease affects approximately 1 out of 8 women in the US. Chemotherapy and/or hormonal therapy have shown some improved disease-free and/or overall survival rates. Unfortunately, this type of therapy is not directed specifically to the malignant cells, and systemic toxicities are observed. In order to develop site-specific treatment, the biology of the disease must be understood such that certain genes or their products which are involved in the pathogenesis of the disease can be targeted. Two structurally related tyrosine kinase growth factors, the epidermal growth factor receptor (EGFR) and c-erbB-2 (neu) have been identified in human breast cancer tissue and, in many instances, may function as oncogenes. The clinical data related to these two growth factor receptors as prognostic factors for the disease have been critically evaluated. Several problems with the critical studies were identified, and solutions were proposed to clarify the conflicting results reported in the studies which have attempted to examine whether c-erbB-2 (neu), in particular, is a prognostic indicator for breast cancer. In addition, data related to the structure of, ligands for and interaction between the proteins have been reviewed and presented with respect to their role in breast cancer development. A more thorough understanding of the genetic changes which contribute to the development of breast cancer will lead to more specific and less toxic treatment for this disease.

STUDY OBJECTIVES: To determine the frequency of classical markers of non-rapid eye movement (NREM) parasomnias--hypersynchronous delta sleep (HSD) electroencephalogram waves and sudden arousals from slow-wave sleep (SWS)--in patients without histories of somnambulism or other NREM parasomnias. DESIGN: Retrospective review. SETTING: Sleep disorders center laboratory. PATIENTS: 82 consecutive patients without a history of parasomnias who underwent diagnostic polysomnograms; 57 men and 25 women, mean age 48+/-13.3 years, were included without regard to diagnosis or findings. All patients had at least 30 seconds of stage 3 or 4 sleep during the polysomnogram. MEASUREMENTS AND RESULTS: The primary diagnosis of all but 4 patients was obstructive sleep apnea (mean respiratory disturbance index, 30 +/- 23.6 [range, 2.7-117] per hour of sleep). Polysomnograms were then reviewed for the presence of HSD and SWS arousals. A total of 235 arousals (mean, 2.9 +/- 2.7; range, 0-14) from stage 3 or 4 sleep were noted. Eight-five percent of all patients had at least 1 SWS arousal and 45% had 3 or more SWS arousals; 85.1% of all arousals from SWS were secondary to sleep-disordered breathing, and 5.9% were secondary to leg movements. At least 1 episode of HSD (mean, 1.4 +/- 1.6; range, 0-9) was noted in 65.8% of patients. CONCLUSIONS: HSD and SWS arousals were a common finding in patients without clinical histories of sleepwalking or other parasomnias but who were found to have frequent respiratory-related arousals during sleep. HSD and SWS arousals thus have a low specificity for NREM parasomnias and, without further research, are not useful for the objective confirmation of parasomnias in clinical evaluations and in the forensic evaluation of sleepwalking as a legal defense.

A2A adenosine receptors specifically found on striatal medium spiny neurons play a major role in sensory motor function and may also be involved in neuropsychiatric and neurodegenerative disorders. One hypothesis concerning Huntington's disease (HD) proposes that an imbalance of the cortico-striatal pathway, due to the mutation in the HD gene, leads to striatal vulnerability. An A2A receptor dysfunction has been previously demonstrated in striatal cells engineered to express mutant huntingtin. Here we tested whether a similar dysfunction (i.e., the binding and functional parameters of A2A adenosine receptors) is present in peripheral blood cells (platelets, lymphocytes, and neutrophils) of subjects carrying the mutant gene. This study involved 48 heterozygous and three homozygous patients compared with 58 healthy subjects. Moreover, we selected seven at-risk mutation carriers. A2A receptor density and function are substantially increased in peripheral blood cells from both patients and subjects at the presymptomatic stage. In the neutrophils of the three homozygous HD subjects receptor dysfunction was higher than in heterozygotes. These data indicate the existence of an aberrant A2A receptor phenotype in the peripheral blood cells of subjects carrying the HD mutation. Future studies will assess whether this parameter can be exploited as a peripheral biomarker of Huntington's disease.

OBJECTIVE: To determine type, distribution, and radiographic appearance of condylar fractures of the third metacarpal bone (MC-3) or third metatarsal bone (MT-3) in Thoroughbreds (TB), Standardbreds (SB), and Arabians, to assess long-term outcome of horses in which fractures were repaired surgically, and to identify variables associated with prognosis for return to racing. DESIGN: Retrospective study. ANIMALS: 224 horses with 233 fractures. PROCEDURE: Medical records and radiographs obtained before and after treatment were reviewed. Racing performance before and after treatment was determined by reviewing race records. RESULTS: TB were overrepresented and SB were underrepresented, compared with the hospital population. Thoroughbreds had significantly more lateral condylar fractures and significantly more forelimb fractures than did SB. Thoroughbreds were less likely to race after treatment if they had complete, rather than incomplete, lateral condylar fracture or had concurrent proximal sesamoid bone fracture. Convalescent time for TB with medial condylar fractures of MT-3 was significantly longer than that for TB with lateral condylar fractures of MT-3. CLINICAL IMPLICATIONS: Horses with condylar fractures of MC-3 and MT-3 that had minimal pathologic changes in the involved joint had a favorable prognosis for returning to racing after surgical treatment. Prognosis for horses with complete condylar fractures, particularly those with substantial pathologic changes in the involved joint, was worse.

This research reports the results of a bibliometric study of nine volumes of the Journal of the American Society for Information Science (JASIS): 1972–1974, 1982–1984, and 1988–1990. For each full-length article, values of six variables were recorded: the year the article was published, the number of citations to the article, the funding status of the work (funded or not funded), the funding agency (if funded), the subject of the paper, and the institutional affiliation of the first author, and several hypotheses were tested. No relationship was found between whether an article was funded and the quality or utility of the article, as measured by the number of subsequent citations to the work. Funding for information science research has declined, especially at the federal levels. JASIS authors who are affiliated with schools of library and information science have the most difficulty in having their work funded, although the work produced by this group of authors is the most highly cited. While the emphasis on theoretical work has remained essentially constant over the past 20 years, the number of articles related to professional issues and related fields has increased, and the number of articles classified as applied has decreased. More JASIS authors are coming from academic departments in universities; fewer are information practitioners. Information science is developing as a discipline and moving away from its practice-oriented roots. © 1992 John Wiley & Sons, Inc.

Dimethylformamide (DMF), a widely used and versatile industrial solvent, has been reported to cause abdominal pain and hepatic abnormalities. An accidental dermal and respiratory exposure to DMF produced severe abdominal pain, hypertension, leukocytosis, and hepatic damage in a fabric coating worker. Pain began 62 hours after DMF exposure and was associated with positive results from a Watson-Schwartz test for urine porphobilinogen.

Chrysotherapy was given to 14 patients with refractory psoriatic polyarthritis and to a comparable group of 42 patients with rheumatoid arthritis. The psoriatic patients had a higher rate of remission on gold and less severe toxicity than the rheumatoid arthritis patients. Psoriatic skin lesions were not affected by chrysotherapy.

AIMS: , IBSA) to dimethyl sulfoxide (DMSO). METHODS: Randomized, open-label, multicenter study involving 110 women with BPS/IC. The allocation ratio (HA/CS:DMSO) was 2:1. Thirteen weekly instillations of HA (1.6%)/CS (2.0%) or 50% DMSO were given. Patients were evaluated at 3 (end-of-treatment) and 6 months. Primary endpoint was reduction in pain intensity at 6 months by visual analogue scale (VAS) versus baseline. Secondary efficacy measurements were quality of life and economic analyses. RESULTS: A significant reduction in pain intensity was observed at 6 months in both treatment groups versus baseline (P < 0.0001) in the intention-to-treat population. Treatment with HA/CS resulted in a greater reduction in pain intensity at 6 months compared with DMSO for the per-protocol population (mean VAS reduction 44.77 ± 25.07 vs. 28.89 ± 31.14, respectively; P = 0.0186). There were no significant differences between treatment groups in secondary outcomes. At least one adverse event was reported in 14.86% and 30.56% of patients in the HA/CS and DMSO groups, respectively. There were significantly fewer treatment-related adverse events for HA/CS versus DMSO (1.35% vs. 22.22%; P = 0.001). Considering direct healthcare costs, the incremental cost-effectiveness ratio of HA/CS versus DMSO fell between 3735€/quality-adjusted life years (QALY) and 8003€/QALY. CONCLUSIONS: Treatment with HA/CS appears to be as effective as DMSO with a potentially more favorable safety profile. Both treatments increased health-related quality of life, while HA/CS showed a more acceptable cost-effectiveness profile.