Successful Late Management of Esophageal Perforation with T-Tube Drainage

The late management of spontaneous esophageal perforation is the most challenging problem for the surgeon. In this paper, we present a case in whom a spontaneous esophageal perforation was successfully treated by T-tube drainage after unsuccessful conservative treatment. The patient, a 68-year-old male, was admitted to the hospital with sudden upper abdominal pain. After 2 days, esophageal perforation was diagnosed, and conservative management was begun. Thereafter, the subcutaneous emphysema disappeared, and the patient's temperature decreased. However, on day 13, the patient's temperature spiked above 38°C, and computed tomography showed a mediastinal abscess. An emergency left thoracotomy with laparotomy was performed. Since a 2-cm longitudinal perforation with severe inflammatory reactions was observed, the T-tube drainage method was performed. The patient was discharged without postoperative complications and has not experienced any gastrointestinal symptoms, such as gastroesophageal reflux or dysphagia. In conclusion, the T-tube drainage method appears to be a simple and effective method for the late management of esophageal perforation with severe inflammatory reaction

Successful Surgical Treatment of a Spontaneous Rupture of the Esophagus Diagnosed Two Days after Onset

Esophageal perforation is a relatively uncommon disease with a high rate of mortality and morbidity. Delay in the diagnosis and treatment occurs in more than 50% of cases, leading to a mortality rate of 40–60%. Primary repair is generally considered the gold standard for patients who present within the first 24 h following perforation of the esophagus. In this paper, we present a case of successful surgical treatment of spontaneous rupture of the esophagus that was diagnosed 2 days after onset. The patient was a 42-year-old man admitted to internal medicine with a diagnosis of pleuritis and complaining of chest and back pain. The next day, computed tomography revealed left-sided pleural effusion and mediastinal emphysema. An esophagogram revealed extravasation of the contrast medium from the lower left esophagus to the mediastinal cavity. These results confirmed a rupture of the esophagus, and an emergency left thoracotomy was performed. The perforation was repaired with a single-layered closure and was covered with elevated great omentum obtained by laparotomy. The patient was discharged 23 days after the first surgery. In conclusion, primary repair surgery must be selected as the best treatment beyond 24 h if the patient's general state was stable and there was no evidence of clinical sepsis

Quorum Sensing Regulation of the Two hcp Alleles in Vibrio cholerae O1 Strains

BACKGROUND: The type VI secretion system (T6SS) has emerged as a protein secretion system important to several gram-negative bacterial species. One of the common components of the system is Hcp, initially described as a hemolysin co-regulated protein in a serotype O17 strain of Vibrio cholerae. Homologs to V. cholerae hcp genes have been found in all characterized type VI secretion systems and they are present also in the serotype O1 strains of V. cholerae that are the cause of cholera diseases but seemed to have non-functional T6SS. METHODOLOGY/PRINCIPAL FINDINGS: The serotype O1 V. cholerae strain A1552 was shown to express detectable levels of Hcp as determined by immunoblot analyses using polyclonal anti-Hcp antiserum. We found that the expression of Hcp was growth phase dependent. The levels of Hcp in quorum sensing deficient mutants of V. cholerae were compared with the levels in wild type V. cholerae O1 strain A1552. The expression of Hcp was positively and negatively regulated by the quorum sensing regulators HapR and LuxO, respectively. In addition, we observed that expression of Hcp was dependent on the cAMP-CRP global transcriptional regulatory complex and required the RpoN sigma factor. CONCLUSION/SIGNIFICANCE: Our results show that serotype O1 strains of V. cholerae do express Hcp which is regarded as one of the important T6SS components and is one of the secreted substrates in non-O1 non-O139 V. cholerae isolates. We found that expression of Hcp was strictly regulated by the quorum sensing system in the V. cholerae O1 strain. In addition, the expression of Hcp required the alternative sigma factor RpoN and the cAMP-CRP global regulatory complex. Interestingly, the environmental isolates of V. cholerae O1 strains that showed higher levels of the HapR quorum sensing regulator in comparison with our laboratory standard serotype O1 strain A1552 where also expressing higher levels of Hcp

Comparative genomics of the type VI secretion systems of Pantoea and Erwinia species reveals the presence of putative effector islands that may be translocated by the VgrG and Hcp proteins

<p>Abstract</p> <p>Background</p> <p>The Type VI secretion apparatus is assembled by a conserved set of proteins encoded within a distinct locus. The putative effector proteins Hcp and VgrG are also encoded within these loci. We have identified numerous distinct Type VI secretion system (T6SS) loci in the genomes of several ecologically diverse <it>Pantoea </it>and <it>Erwinia </it>species and detected the presence of putative effector islands associated with the <it>hcp </it>and <it>vgrG </it>genes.</p> <p>Results</p> <p>Between two and four T6SS loci occur among the <it>Pantoea </it>and <it>Erwinia </it>species. While two of the loci (T6SS-1 and T6SS-2) are well conserved among the various strains, the third (T6SS-3) locus is not universally distributed. Additional orthologous loci are present in <it>Pantoea </it>sp. aB-valens and <it>Erwinia billingiae </it>Eb661. Comparative analysis of the T6SS-1 and T6SS-3 loci showed non-conserved islands associated with the <it>vgrG </it>and <it>hcp</it>, and <it>vgrG </it>genes, respectively. These regions had a G+C content far lower than the conserved portions of the loci. Many of the proteins encoded within the <it>hcp </it>and <it>vgrG </it>islands carry conserved domains, which suggests they may serve as effector proteins for the T6SS. A number of the proteins also show homology to the C-terminal extensions of evolved VgrG proteins.</p> <p>Conclusions</p> <p>Extensive diversity was observed in the number and content of the T6SS loci among the <it>Pantoea </it>and <it>Erwinia </it>species. Genomic islands could be observed within some of T6SS loci, which are associated with the <it>hcp </it>and <it>vgrG </it>proteins and carry putative effector domain proteins. We propose new hypotheses concerning a role for these islands in the acquisition of T6SS effectors and the development of novel evolved VgrG and Hcp proteins.</p

Genetic Variants of Human Granzyme B Predict Transplant Outcomes after HLA Matched Unrelated Bone Marrow Transplantation for Myeloid Malignancies

Serine protease granzyme B plays important roles in infections, autoimmunity, transplant rejection, and antitumor immunity. A triple-mutated granzyme B variant that encodes three amino substitutions (Q48R, P88A, and Y245H) has been reported to have altered biological functions. In the polymorphism rs8192917 (2364A>G), the A and G alleles represent wild type QPY and RAH mutant variants, respectively. In this study, we analyzed the impact of granzyme B polymorphisms on transplant outcomes in recipients undergoing unrelated HLA-fully matched T-cell-replete bone marrow transplantation (BMT) through the Japan Donor Marrow Program. The granzyme B genotypes were retrospectively analyzed in a cohort of 613 pairs of recipients with hematological malignancies and their unrelated donors. In patients with myeloid malignancies consisting of acute myeloid leukemia and myelodysplastic syndrome, the donor G/G or A/G genotype was associated with improved overall survival (OS; adjusted hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.41–0.89; P = 0.01) as well as transplant related mortality (TRM; adjusted HR, 0.48; 95% CI, 0.27–0.86, P = 0.01). The recipient G/G or A/G genotype was associated with a better OS (adjusted HR, 0.68; 95% CI, 0.47–0.99; P = 0.05) and a trend toward a reduced TRM (adjusted HR, 0.61; 95% CI, 0.35–1.06; P = 0.08). Granzyme B polymorphism did not have any effect on the transplant outcomes in patients with lymphoid malignancies consisting of acute lymphoid leukemia and malignant lymphoma. These data suggest that there is an association between the granzyme B genotype and better clinical outcomes in patients with myeloid malignancies after unrelated BMT

Ectopic expression of the serine protease inhibitor PI9 modulates death receptor-mediated apoptosis.

Apoptosis is a highly controlled process, whose triggering is associated with the activation of caspases. Apoptosis can be induced via a subgroup of the tumor necrosis factor (TNF) receptor superfamily, which recruit and activate pro-caspase-8 and -10. Regulation of apoptosis is achieved by several inhibitors, including c-FLICE-inhibitory protein, which prevents apoptosis by inhibiting the pro-apoptotic activation of upstream caspases. Here we show that the human intracellular serine protease inhibitor (serpin), protease inhibitor 9 (PI9), inhibits TNF-, TNF-related apoptosis-inducing ligand- and Fas ligand-mediated apoptosis in certain TNF-sensitive cell lines. The reactive center P1 residue of PI9 was required for this inhibition since PI9 harboring a Glu --&amp;gt; Ala mutation in its reactive center failed to impair death receptor-induced cell death. This suggests a classical serpin-protease interaction. Indeed, PI9 inhibited apoptotic death by directly interacting with the intermediate active forms of caspase-8 and -10. This indicates that PI9 can regulate pro-apoptotic apical caspases

Extension injury of the thoracic spine with rupture of the oesophagus and successful conservative therapy of concomitant mediastinitis

The case of an upper oesophageal perforation as a concomitant injury of an isolated fracture of the upper thoracic spine without neurological compromise has not been described so far. A Case report and review of the literature is presented here. Concomitant oesophageal perforations carry a high risk of being missed initially. CT alone can visualize the subtle indirect signs like peri-oesophageal air. The literature revealed that only peri-oesophageal air might be a valid indicator of oesophageal injury. There are no systematic data on thoracic spine fractures with concomitant oesophageal perforations. Mediastinitis secondary to oesophageal perforation might be treated conservatively with endoscopic stent placement rather than surgically. As the radiological signs of concomitant soft tissue injury, like oesophageal perforations, in fractures of the upper thoracic spine are subtle and easily missed initially only anticipation of concomitant injuries by the treating physician based on the trauma mechanism ensures a timely diagnosis

Corpos estranhos caminham pelo corpo em direção ao coração? Do foreign bodies migrate through the body towards the heart?

A fixação dos CE, principalmente os pontiagudos, favorece a migração pelo corpo, gerando a expressão popular: "os CEs caminham pelo corpo em direção ao coração". OBJETIVO: Descrever os mecanismos envolvidos na migração do CE e a forma de diagnosticá-los. METODOLOGIA: Numa população de 3.000 casos de corpos estranhos, em 40 anos, foram analisados quatro que tiveram deslocamento extraluminal. Foram tomados os dados clínicos, radiológicos, endoscópicos e ultrassonográficos coletadas no serviço de documentação médica. RESULTADOS: São apresentadas três histórias clínicas em que o CE era de espinha de peixe e uma de cartilagem de peixe. Em todos se analisou o deslocamento. Em dois a migração se iniciou no esôfago, um para a aorta e outro para a região cervical e nos dois outros, o deslocamento ocorreu a partir da faringe: um para a fáscia pré-vertebral e outro se exteriorizou na região submandibular. Discutem os mecanismos pelos quais ocorre a migração dos CEs pelo corpo e os riscos que tais deslocamentos promovem para o paciente e a forma de diagnosticá-los. CONCLUSÕES: Os CE podem caminhar pelo corpo, porém não para o coração. Em casos de histórias arrastadas de ingestão de CEs, o estudo por imagens se faz obrigatório, previamente ao exame endoscópico.<br>Fixation of foreign bodies (FB), in the mucosa, can favor its migration, giving origin to the popular saying: "FB walk to the heart". AIM: describe the mechanisms involved in FB migration and how to diagnose them. METHODOLOGY: From a sample of 3,000 foreign bodies, during 40 years, we analyzed four which had extra-lumen migration. We analyzed clinical, radiologic, endoscopic and ultrasound data collected at the medical documentation service. RESULTS: three clinical histories are presented, describing two fish bones and one piece of fish cartilage. FB shifting was analyzed in all of them. Migration started in the esophagus in two, one going to the aorta and the other to the neck area. In the other two, migration started in the pharynx, and the FB moved towards the prevertebral fascia and the other externalized in the submandibular region. The mechanisms and the risks posed to the patient, by FB migration, and the way to diagnose them are hereby discussed. CONCLUSIONS: the study allows us to determine that FB can move through the body but not towards the heart. The study also serves as a warning sign: in cases of prolonged histories of FB ingestion, imaging studies are mandatory before endoscopic examination