D F Du Toit

Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty: a reappraisal of the vertebral venous system.

Objectives. To focus attention of the clinician on the anatomy and (patho)physiology of the vertebral venous system, so as to offer a tool to better understand and anticipate (potential) complications that are related to the application of percutaneous vertebroplasty and kyphoplasty. Background. Percutaneous vertebroplasty and kyphoplasty are newly developed, minimally invasive techniques for the relief of pain and for the strengthening of bone in vertebral body lesions. With the clinical implementation of these techniques, a number of serious neurologic and cardiopulmonary complications have been reported in the international medical literature. Most complications appear to be related to the extrusion of bone cement into the vertebral venous system. Methods. The literature about complications of percutaneous vertebroplasty and kyphoplasty is reviewed, and the anatomic and (patho)physiologic characteristics of the vertebral venous system are reported. Based on what is currently known from the anatomy and physiology of the vertebral venous system, the procedures of percutaneous vertebroplasty and kyphoplasty are analyzed, and suggestions are made to improve the safety of these techniques. Conclusions. Thorough knowledge of the anatomic and (patho)physiologic characteristics of the vertebral venous system is mandatory for all physicians that participate in percutaneous vertebroplasty and kyphoplasty. To reduce the risk of cement extrusion into the vertebral venous system during injection, vertebral venous pressure should be increased during surgery. This can be achieved by operating the patient in the prone position and by raising intrathoracic venous pressure with the aid of the anesthesiologist during intravertebral instrumentation and cement injection. Intensive theoretical and practical training, critical patient selection, and careful monitoring of the procedures, also taking into account patient positioning and intrathoracic and intra-abdominal pressures, will help to facilitate low morbidity outcomes inthese very promising minimally invasive techniques.

The sensory branch distribution of the suprascapular nerve: an anatomic study.

The suprascapular nerve is responsible for most of the sensory innervation to the shoulder joint and is potentially at risk during surgery. In this study, 31 shoulders in 22 cadavers were dissected to investigate the sensory innervation of the shoulder joint by the suprascapular nerve, with special reference to its sensory branches. In 27 shoulders (87.1%), a small sensory branch was observed that splits off from the main stem of the suprascapular nerve proximal (48.2%), inferior (40.7%), or distal (11.1%) to the transverse scapular ligament. This percentage is considerably higher than has been previously found. In 74.2% of the shoulders, an acromial branch was also found, originating just proximal to the scapular neck, running to the infraspinatus tendon. These cadaveric results indicate that sensory branches to the shoulder joint are more common and numerous than previously described and therefore should be considered in shoulder surgery and nerve blocks to this area.

Hyperglycaemia and reduced glucokinase expression in weanling offspring from dams maintained on a high-fat diet

High-fat feeding reduces the expression of GLUT-2 and the glycolytic enzyme glucokinase (GK). The transcription factor, pancreatic duodenal homeobox-1 (Pdx-1), is important for beta-cell maintenance. The aim of the present study was to determine, in weanling Wistar rats, the effect of a maternal high-fat diet (HFD) during defined periods of gestation and lactation, on body weight, circulating glucose and insulin concentrations, and the expression of GLUT-2, GK and Pdx-1. At postnatal day 21, weights were recorded and glucose and insulin concentrations were measured. The expression levels for mRNA were quantified by LightCycler PCR. Pancreatic sections, immunostained for GLUT-2, GK or Pdx-1, were assessed by image analysis. Weanlings from dams fed an HFD throughout gestation were lighter, with heavier weanlings produced from dams fed an HFD throughout gestation and lactation. Both these groups of weanlings were normoglycaemic, all the others being hyperglycaemic. Hypoinsulinaemia was evident in weanlings from dams fed an HFD throughout gestation only and also for either the first week of lactation or throughout lactation. GLUT-2 mRNA expression was reduced and GLUT-2 immunoreactivity was increased in most of the weanlings. GK mRNA expression and immunoreactivity was reduced in most of the offspring. Pdx-1 mRNA expression was increased in weanlings from dams fed an HFD throughout both gestation and lactation and reduced in those from dams only fed a lactational HFD. Normal Pdx-1 immunoreactivity was found in all of the weanlings. A maternal HFD induces hyperglycaemia in weanlings concomitant with reduced GK expression which may compromise beta-cell function.

fluoxetine decreases stereotypic behavior in primates

BACKGROUND Primates reared in captivity may display stereotypic behaviors. These behaviors are arguably reminiscent of human obsessive-compulsive or posttraumatic symptoms, which respond to selective serotonin reuptake inhibitors (SSRIs). Captive primates with marked stereotypic behaviors were entered into a randomized controlled study of the SSRI, fluoxetine. METHODS A sample of 10 vervet monkeys with behaviors such as marked saluting, somersaulting, weaving, or head tossing was selected. Subjects were randomized to receive fluoxetine 1 mg/kg for 6 weeks (n=5) or no treatment (n=5). A rater blind to the medication status of subjects noted the frequency of the stereotypic behaviors. RESULTS Repeated-measures analysis of variance (RM-ANOVA) demonstrated a significant GroupxTime difference with significantly fewer stereotypic symptoms in the fluoxetine group by endpoint. At this time, three of the five fluoxetine-treated subjects (but none of the no-treatment subjects) were responders on the Clinical Global Impressions (CGI) change item (CGI < or =2). CONCLUSIONS Stereotypic behaviors in captive vervets gradually and partially decrease in response to administration of an SSRI, paralleling research on human anxiety symptoms. Further research on animal stereotypies may be useful in providing appropriate veterinary care, and in exploring the underlying neurobiology of certain psychiatric disorders.

THE NON-HUMAN PRIMATE ENDOCRINE PANCREAS : DEVELOPMENT, REGENERATION POTENTIAL AND METAPLASIA

An investigation into the development of the Vervet monkey endocrine pancreas revealed a sequence of occurrence of pancreatic peptides that differed from previous reports in mice, dog and human with PP and somatostatin occurring before glucagon and insulin. All four pancreatic peptides were identified, immunohistochemically, in only one of the pancreatic primordial buds, before fusion of the two buds to form the pancreas. This questions the hypothesis that the heterogeneous endocrine cell distribution seen in the adult pancreas is due to the contribution of only PP cells by the ventral bud and non‐PP cells by the dorsal bud. Co‐localization of glucagon and PP was observed extensively in the developing pancreas and the predominant expression of one over the other in an apparently organized non‐random manner accounted for the glucagon‐ and PP‐rich areas seen in the developing pancreas. A small number of cells immunoreactive to glucagon and PP were also observed in the adult. Reports of plasticity of differentiation of other pancreatic cells led us to investigate regeneration potential of the adult monkey pancreas. Partial obstruction of the Vervet monkey main pancreatic duct, by cellophane wrapping, resulted in duct cell proliferation and differentiation to form new endocrine tissue in a way that mimics normal organogenesis. Focal areas of hepatocytes were found in the regenerated pancreas of one monkey, illustrating further the latent developmental capabilities of adult pancreas cells. These findings could lead to interesting new therapies for pancreas and liver disease.

Surgical and Endovascular Management of Penetrating Innominate Artery Injuries

OBJECTIVE To review our management of penetrating innominate artery injuries by open and endovascular techniques. METHODS Data regarding patient demography, clinical presentation, investigations, associated injuries, pathology, management, complications and mortality, were collected on patients treated at a single centre over 18 years. RESULTS 39 innominate artery injuries were treated. There were 36 men and three women, with a mean age of 27 years (range 18-49). Thirty-eight injuries were due to stabwounds and one was the result of a gunshot wound. The most common clinical presentations were shock (47%) and haematoma(42%). Twenty-three patients had associated injuries. The most common pathology was false aneurysm in 21 patients followed by 13 actively bleeding injuries, 4 arteriovenous fistulas and 1 arterial occlusion. Thirty-four patients underwent surgical and five endovascular repair. Overall survival was 79%. The stroke rate for surviving patients was 6%. Patients treated with endovascular stenting had shorter hospital and intensive care unit stays than those treated with surgery. CONCLUSIONS Innominate artery injuries have high rates of morbidity and mortality. A vascular surgical approach with pre-operative angiography, when possible and careful surgical planning by a dedicated team promotes better surgical results. Endovascular and hybrid procedures can become the method of choice when treating stable patients.

Perspectives on a South African Tutor/Mentor Program: The Stellenbosch University Experience.

The development, implementation and perpetuation of a student academic and social support system has become an imperative strategy at South African universities. Access to tertiary education has, since 1994, systematically transformed institutions until they represent the demographic profile of the country. Previously disadvantaged groupings (black, coloured, female, handicapped, Indian, mixed ancestry) now frequent lecture halls and campuses, many of whom need additional support mechanisms to enhance their chances of success. This article deals with the University of Stellenbosch experience over a six‐year period and the development of a uniquely African tutor/mentor system which not only serves the student who is most at risk of failing, but also enhances the level of achievement of gifted students, many of whom are traditionally underachievers.

An immunocytochemical profile of the endocrine pancreas using an occlusive duct ligation model.

CONTEXT Ligation of the pancreatic duct, distally to its confluence into the bile duct has been shown to induce endocrine tissue regeneration. The surplus endocrine tissue formed is presumed to be able to replace pathologically and/or experimentally compromised tissue. OBJECTIVE This is a quantitative study on the histology of duct ligated pancreas employing immunocytochemistry and computerised morphometry. INTERVENTIONS Pancreatic duct ligation was performed on 25 groups of six normal Sprague-Dawley rats. Experimental animals were sacrificed at 12-hour intervals from day one to ten post-duct ligation and every 24 hours thereafter to day 14, the pancreas removed, fixed and processed. Six consecutive 3-6 micron serial sections were cut on a rotary hand microtome, floated onto 3-aminopropyl-trimethoxysilan coated slides and alternatively immunocytochemically stained for insulin, glucagon, pancreatic polypeptide and somatostatin. RESULTS Pancreas transformation between days 1/2 and 3 1/2 was characterised by acinar deletion and the appearance of immunoreactive cells for the primary endocrine hormones. Transdifferentiation of existing endocrine tissue saw islet insulin core cells replaced by pancreatic polypeptide- and somatostatin positive cells, glucagon deletion and random appearance of all endocrine cell types within the inter-islet interstitium by day 3 1/2. Days 4 to 14 were characterised by cellular migration and islet reconstruction. CONCLUSIONS To date our laboratory has investigated transplantation of foetal tissue beneath the renal capsule in syngeneic, isogeneic and allogeneic normal and diabetic rats. As pancreatic duct ligation induces the development of surplus endocrine tissue our next step would be to investigate the use of ligated pancreas as a replacement for foetal tissue.

Foetal rat pancreatic transplantation: posttransplantation development of foetal pancreatic iso- and allografts and suppression of rejection with mycophenolate mofetil (MMF) and cyclosporine based immunesuppression

Provided engraftment can be ensured, vascularization promoted, and ischaemic damage due to storage prevented, foetal pancreatic transplantation (FPT) has the potential to ameliorate the endocrine and metabolic disturbances in diabetic animal models including hyperglycaemia. In a syngeneic Wistar rat substrain (WAG) model (WAG → WAG), FPT was capable of restoring normoglycaemia in diabetic rats rendered diabetic by streptozotocin (STZ). Post‐transplantation growth and development of the foetal tissue was characterised by acinar atrophy, preservation of islet tissue, and development and proliferation of fat accumulations at the site of engraftment. B‐ and A‐cell staining and distribution on ICC appeared normal after 12 months. Mycophenolate mofetil (MMF) together with cyclosporine (CSA) was selected to suppress rejection of foetal rat pancreatic allografts in a strong responder allogeneic model (WAG → Sprague‐Dawley). MMF, a novel immunosuppressive agent that selectively inhibits de novo purine synthesis, was administered in combination with subtherapeutic doses of CSA (2 mg/kg/day) to prevent rejection after allogeneic foetal rat pancreatic transplantation. Although CSA monotherapy in this model can partially suppress rejection, the combination of CSA and MMF results in significant inhibition of acute allograft rejection and mononuclear cellular (MNC) infiltration as assessed by sequential histology post‐operatively. Although the follow‐up period of allografts was restricted to 30 days of treatment, histology showed low graft infiltrate scores (1.2+) and preservation of islets and immunocytochemical staining. The results in this animal transplantation model confirm that sub‐therapeutic doses of MMF and CSA therapy are effective in preventing acute rejection of foetal rat pancreatic allografts in the short‐term, thus allowing preservation of vital endocrine components of the foetal pancreas such as islets. Microsc. Res. Tech. 43:343–355, 1998.

Development, differentiation, and regeneration potential of the Vervet monkey endocrine pancreas.

Using immunolabelling techniques, characterization of the Vervet monkey pancreas included a study of both its development and its structure and normal functioning in the adult. We found that PP and somatostatin occurred during development before glucagon. Insulin and all four pancreatic peptides occurred in one of the primordial buds prior to fusion. These finding call into question the suggested contribution of only PP cells by the ventral bud and non‐PP cells by the dorsal bud. Co‐localization of glucagon and PP was observed extensively with their relative expressions occurring in what appeared to be an organised non‐random manner. Cells expressing both glucagon and PP persisted in the adult, together with many other combinations, suggesting an interesting plasticity of endocrine cell differentiation in the adult. Cellophane wrapping of the head of the Vervet monkey pancreas was shown to result in a noticeable increase in duct cell proliferation and endocrine cell volume but no increased replication of endocrine cells. Cells, immunoreactive for pancreatic peptides, were observed to bud from the ducts, suggesting a regeneration of endocrine cell tissue by neogenesis, although it is uncertain whether the duct epithelium contains the only stem cell source of new endocrine tissue. Hopefully, further investigations will elucidate a mechanism by which endocrine cell regenerative capacity can be stimulated in diabetics to overcome their absolute or relative deficiencies of insulin production. Microsc. Res. Tech. 43:322–331, 1998.