Proximal Spread Research Articles

Cutaneous tuberculosis mimicking sporotrichosis

The authors describe an unusual presentation of lupus vulgaris in a 5-year-old boy. The lesions had a linear arrangement with proximal spread mimicking sporotrichosis. Histopathology of the lesions revealed tuberculoid granulomas. Tubercular etiology was confirmed by the demonstration of acid fast bacilli in the smears from the regional lymph node aspirate stained with Ziehl Neelsen stain, and growth of Mycobacterium tuberculosis in the aspirate culture. The patient showed marked improvement of his lesions on anti-tubercular treatment.

Oral Mesalazine (5-ASA) Treatment May Protect Against Proximal Extension of Mucosal Inflammation in Ulcerative Proctitis

Studies aimed at establishing which characteristics of patients with ulcerative proctitis could be predictive of the extension of inflammation have failed to provide conclusive results. The aim of the study was to evaluate the prognostic role of clinical and therapeutic parameters in patients with proctitis. Case records of 138 patients with ulcerative proctitis were retrospectively evaluated. The following parameters were considered: gender; age at onset of disease; smoking habits; histologic severity of disease at onset; mean number of clinical relapses of disease per year; mean duration of oral and topical mesalazine treatment; and number of topical corticosteroid treatments per year. Twenty-eight patients were excluded from the analysis for different reasons. During follow-up, inflammation spread proximally in 33 of 110 patients (30%). Patients with extended proctitis showed a significantly higher number of relapses and a shorter duration of oral mesalazine treatment than patients with nonprogressive proctitis (p < 0.001 for both). The multivariate analysis also found that the mean duration of topical mesalazine treatment was longer in patients with extended proctitis. Ulcerative proctitis patients with more frequent relapses who need a longer duration of topical therapy are at higher risk of extension of the disease, while a more prolonged oral mesalazine treatment period protects against the proximal spread of rectal inflammation.

The anatomical rationale for an upper limb sympathetic blockade: preliminary report.

Stellate ganglion blockade (SGB) has long been considered pivotal in the diagnosis, determination of prognosis and management of chronic regional pain syndrome (CRPS) by sympathectomy. To date a variety of SGB techniques have been described. An inaccurate SGB may mislead clinicians and deny patients a potentially beneficial procedure. In order to obtain a predictable and readily reproducible blockade of the upper limb, a modified anterior technique was evaluated. This modified sympathetic block was performed in 10 adult cadavers (n=19 sides). Toluidine blue solution (10 ml) was injected and, following median sternotomy, the extent of spread of dye was evaluated. In one cadaver a dual block using both the modified and the standard techniques was performed. Proximal spread to the seventh cervical vertebra was noted in all blocks; distal spread extended to the neck of the third rib (n=3), neck of the fourth rib 7 (n=15) and neck of the seventh rib (n=1). Medial spread was greater than lateral spread and extended to the vertebral bodies (vagus nerve was also stained) while lateral spread in all cases "blocked" lower roots of the brachial plexus and was consistently noted beyond the usual location of the nerve of Kuntz. This modified technique demonstrated that the lower cervical ganglia and proximal thoracic sympathetic trunk were consistently stained. It should be noted that the spread was sufficiently lateral to block the nerve of Kuntz. The pitfalls of this technique aside, we suggest that this technique be reserved for therapeutic purposes, particularly when sympathectomy is not possible.

Genetic background modifies intestinal pseudo-obstruction and the expression of a reporter gene in Hox11L1−/− mice

Background & Aims: The transcription factor Hox11L1 is expressed by enteric neurons. Two groups mutated murine Hox11L1, and reported lethal intestinal pseudo-obstruction and colonic hyperganglionosis in many, but not all, homozygous null mutants. We investigated the regulation of Hox11L1 and factors that influence the penetrance of pseudo-obstruction in Hox11L1-null mice. Methods: Expression of β-galactosidase ( lacZ), under control of putative Hox11L1 regulatory sequences, was assessed in transgenic mice wild-type, heterozygous, and null for native Hox11L1. Transgene expression and signs of pseudo-obstruction were compared in null mice with different genetic backgrounds. Results: In enteric neurons and other parts of the nervous system, the transgene was expressed in a pattern consistent with native Hox11L1. Enteric β-galactosidase activity initiated in the proximal small intestine and spread cranially and caudally in a subset of postmitotic enteric neurons. Hox11L1-lacZ transgene expression persisted in Hox11L1-null animals, suggesting that Hox11L1 is not required cell autonomously for neuronal survival. Genetic background dramatically affected the phenotypes of Hox11L1-null animals, with complete penetrance of severe proximal colonic distention on a predominantly C57BL/6J (B6) background and very low penetrance of dysmotility on a 129SvJ (129) background. Coincidently, Hox11L1-lacZ expression by most enteric neurons, but not CNS neurons, was lost on a 129 background. Conclusions: Cis-acting, 5′ regulatory elements are sufficient to regulate site-specific expression of Hox11L1 in vivo. Expression of the transgene by enteric neurons and penetrance of pseudo-obstruction in Hox11L1-null animals are influenced by one or more modifier genes, counterparts of which may play a similar role in human disease.

Acromelanosis

Acromelanosis is an independent disease entity, characterized by increased skin pigmentation, usually located on the acral areas of the fingers and toes. It is mostly seen in newborns or during the first years of life. Only a few cases of this entity have previously been described in the medical literature. In some of these cases, the cutaneous lesions spread to affect large parts of the skin surface. A possible association with other benign and malignant diseases has been proposed. Differential diagnosis must be made with a wide variety of systemic and dermatologic conditions, especially dermatoses with acral distribution of macular hyperpigmentation, including acropigmentation. In this article, we report a new case of acromelanosis in a 5-week-old girl showing two peculiar clinical features: associated melanosis of the genital mucosa and stabilization of the lesions after an initial phase of progression and proximal spread. In addition, the most important features of this rare cutaneous disease are discussed.

Tendon involvement in pedal infection: MR analysis of frequency, distribution, and spread of infection.

The objective of our study was to evaluate the frequency, distribution, and extent of tendon involvement in patients with pedal infections. Contrast-enhanced MR imaging examinations of 159 infected feet performed at 1.5 T were reviewed by two musculoskeletal radiologists for the presence and location of tendon infection (peritendinous enhancement contiguous to an adjacent ulcer or cellulitis) and for the spread of infection along tendons, which was defined as peritendinous contrast enhancement extending more than 2 cm beyond surrounding cellulitis. The study group was composed of 156 consecutive patients, 82.7% of whom had diabetes; all patients underwent subsequent surgical treatment. Results of MR evaluations were compared with the patients' charts and surgical reports. Of the 129 MR examinations showing an infection in the forefoot, MR evidence of tendon involvement in the infection was observed in 56 MR examinations (43%). The sum of involved tendons per ray was as follows: first ray (flexor tendon, n = 19; extensor tendon, n = 13), second (flexor tendon, n = 12; extensor tendon, n = 7), third (flexor tendon, n = 5; extensor tendon, n = 4), fourth (flexor tendon, n = 5; extensor tendon, n = 1), and fifth (flexor tendon, n = 11; extensor tendon, n = 6). Of the 32 MR examinations showing infection in the hindfoot, 14 examinations (44%) showed evidence of tendon involvement, most frequently of the distal Achilles tendon (n = 7). MR evidence of the spread of infection along a tendon was seen in 12 examinations, always with proximal spread of infection; and infection led to the development of an abscess in the central plantar compartment in three patients. Intraoperative evidence of a tendon infection was documented in 11 patients. The surgical procedure was altered because of the tendon infection in six patients. MR evidence of tendon infection is present in approximately half the patients who require surgery for pedal infection. Evidence of spread of the infection along tendons is seen infrequently on MR imaging. Detection of a tendon infection could influence surgical therapy.

Ultrasonographic assessment of topographic anatomy in volunteers suggests a modification of the infraclavicular vertical brachial plexus block

The infraclavicular vertical brachial plexus block, first described by Kilka and coworkers, offers a more proximal spread of anaesthesia for the upper extremity than the classic axillary approach. In this technique, the puncture site is defined as lying at the exact centre of an infraclavicular line (k) between the jugular fossa and the ventral process of the acromion. Our study was designed to determine whether the point so defined (P) corresponds with the optimal puncture site determined sonographically (S) and to develop an improved prediction model. High-resolution ultrasonography was carried out in 59 volunteers to visualize the plexus. Sonography-derived distances and morphometric measurements were used to test accuracy and calculate multiple regressions. We found a clear trend towards a more lateral puncture site. In women, S was significantly (P<0.001) lateral (8 mm) to P. The overall accuracy of the infraclavicular vertical brachial plexus block technique was not sufficient to predict the optimal puncture site reliably. Our resulting improved prediction model is valid for both sexes and is based not just on the centre point but on the absolute length of k (22-22.5 cm). We found that for every 1 cm decrease in k the optimal puncture site moved 2 mm laterally from the exact centre of k, and for every 1 cm increase in k it moved 2 mm medially. The suggested modification should help to increase the success rate of the infraclavicular vertical brachial plexus block while decreasing the rate of potentially severe complications, although individual ultrasonographic guidance is to be recommended whenever possible.

A reply

We are grateful to Drs Troy and Kinirons for their interest in our case report and for their comments. The choice of approach to the brachial plexus in a patient who needs elbow surgery, but who has minimal ventilatory reserve, is a difficult one. The incidence of phrenic nerve paralysis approaches 100% with techniques aimed at the upper reaches of the brachial plexus [1], decreasing progressively with techniques that aim at lower portions of the plexus. Anaesthetic efficacy for elbow surgery also varies with different approaches to the brachial plexus, being relatively low with single-injection techniques in the distal axilla, increasing as one approaches a target area between the coracoid process and the first rib, and then decreasing again above this level, as the lower roots and trunks of the plexus are often missed by blocks such as the interscalene or subclavian perivascular. Variations in technique that may encourage local anaesthetic spread to this ‘coraco-costal’ area (the part of the plexus that can provide anaesthesia of the entire upper limb) have been described: distal pressure and high volume with an axillary approach [2, 3], proximal pressure and high volume with an interscalene approach [4]. As an increased volume of injectate will most likely result in an increase in both proximal and distal spread (even with digital pressure [5]), and if it is accepted that the mechanism of phrenic block is the proximal passage of local anaesthetic within the plexus sheath to the cervical roots, logical choices for anaesthesia in the described circumstances include a distal plexus block with a high volume or an accurately placed ‘coraco-costal’ block with a lower volume. The solutions suggested by your correspondents (multiple injection technique at the axilla or a coracoid-level block) are also wholly acceptable. However, the technique used in a particular situation depends not only on the anatomy, the techniques and the patient, it also depends upon the skills and experience of the operator. We were not experienced in coracoid-level blocks and had had unsuccessful experiences of single-shot axillary blocks for elbow surgery in the awake patient. We therefore chose a technique with which we were becoming increasingly familiar and which targeted the appropriate area of the brachial plexus: the vertical infraclavicular block. We chose a volume of 20 ml of local anaesthetic solution for two reasons: firstly, in order to minimise the proximal spread of local anaesthetic, and thus, we hoped, to reduce the chances of phrenic nerve paralysis; second, it is our contention that 20 ml of local anaesthetic is all that is needed to produce arm, as opposed to arm and shoulder, anaesthesia at a plexus level behind or close to the clavicle. This view is supported by Winnie's demonstrations of the relationship between injection volume and extent of anaesthesia in upper limb blocks [6].

Investigating the proximal limit of lymphadenectomy in patients with adenocarcinoma of the oesophagus in the mid-thoracic region

Abstract Aims The benefit of extended lymphadenectomy in patients with squamous cell carcinoma of the oesophagus is established, but there is little evidence to support this in patients with adenocarcinoma. The aim of this study was to investigate the extent of lymphatic spread of oesophageal adenocarcinomas, and particularly the proximal spread in tumours located in the mid thorax. Methods Twenty-six consecutive patients with tumours arising between 29 and 35 cm from the incisor teeth underwent three-stage oesophagectomy with two-field lymphadenectomy, including nodes in the recurrent laryngeal chains. The proximal extent was measured by endoscopic ultrasonography and confirmed at operation, with division of the lymph node harvest into anatomical sites according to the Japanese classification of oesophageal cancer. Results There were 21 men and five women, with a mean age of 64 (range 42–78) years; seven patients were lymph node negative in both the mediastinal and abdominal fields. Six patients had nodal metastases more than 2 cm above the tumour and all had extensive involvement of other nodes at the level of the tumour or below, with 7, 7, 9, 12, 15 and 18 nodes positive. There were no patients in whom nodes above the tumour contained metastases while those at the level or below were clear. Conclusions Dissection of proximal lymph nodes along the recurrent laryngeal nerve chains in patients with adenocarcinoma of the oesophagus is not warranted. Lymphatic spread above the level of the tumour occurs in association with extensive lymph node involvement elsewhere and removal of proximal nodes from difficult locations is not warranted as a means of improving staging or survival.

The histological extent of the local spread of carcinoma of the penis and its therapeutic implications.

To explore the possibility of reducing the margin of clearance at surgery for carcinoma of the penis without causing an increase in the incidence of local tumour recurrence, so that the functional and cosmetic compromise associated with penectomy might be minimized. Sixty-four patients underwent partial or total penectomy based on the extent of tumour. The specimens were evaluated histologically for grade and for proximal microscopic extensions beyond the grossly visible tumour margin, by examining serial proximal 5 mm sections. The histological grade of the lesion was correlated with its clinical site, morphology and proximal microscopic spread. Differences were assessed using the chi-squared test. Of 64 tumours, 31% were grade 1, 50% grade 2 and the remaining 19% grade 3. Higher grade lesions were more likely to involve the penile shaft. The maximum proximal histological extent was 5 mm for grades 1 and 2, and 10 mm for grade 3 tumours; there was no discontinuous spread. Histological grading is mandatory in the management of carcinoma of the penis. A 10-mm clearance is adequate for grade 1 and 2 lesions, and 15 mm for grade 3 tumours. This approach would qualify more patients for partial rather than total amputation; the residual length of the penis would then be cosmetically and functionally more acceptable.

A 10-year review of high-pressure injection injuries to the hand

High-pressure injection injuries to the hand are uncommon, but often result in poor outcome or even amputation. We report a review of the 28 cases treated surgically in our department over the last 10 years and have examined the factors leading to increased morbidity. The severity of these injuries was related to the nature of the injected material, involvement of the tendon sheath and proximal spread of the injected substance. All cases in which the digit was noted to be poorly perfused from the outset resulted in amputation. We conclude that early amputation should be considered in cases in which the affected digit is initially cool or poorly perfused.

A common epineural sheath for the nerves in the popliteal fossa and its possible implications for sciatic nerve block

Sciatic nerve block in the popliteal fossa is associated with a highly variable success rate. Frequently, anesthesia is profound in the distribution of both the tibia1 (TN) and common peroneal nerves (CPN), although the response to nerve stimulation or paresthesia is obtained in the distribution of one division of the nerve. However, anesthesia in the distribution of only one division of the nerve is also a common recurrence under apparently identical clinical circumstances. Looking for a possible role of a common epineural sheath in these phenomena, we injected dye into the epineural sheath of the tibia1 nerve in 10 cadaver legs and observed its spread within the sheath. Injections of 15 mL and 30 mL of the dye resulted in a proximal spread of 147 2 34 mm and 172 t 50 mm, respectively, from the injection point 10 cm below the popliteal fossa crease. In a majority of the legs, the dye reached the division of the sciatic nerve in the popliteal fossa, bathing both the TN and CPN. Gross inspection and histologic examination of the sciatic nerve specimens revealed a common epineural sheath enveloping the TN and CPN. The presence of the common epineural sheath and its characteristics may have important clinical implications for sciatic nerve blockade in the popliteal fossa.

Regional anesthesia for hand surgery

Several regional anesthetic techniques for hand and wrist surgery are mentioned. Of these techniques, the axillarybrachial plexus block offers several advantages, such as ease of administration, prolongation of analgesia, and very few potential complications. Three conditions must be met to provide effective regional anesthesia: (1) patient instruction, (2) a surgeon comfortable with the technique, and (3) a prepared anesthesiologist. The axillary brachial plexus block is performed aseptically in a manner that promotes proximal spread of local anesthetic, giving the opportunity to block the musculocutaneous nerve before its exit from the sheath. In our institution, we favor 1.5% mepivacaine versus 0.5 bupivacaine because of its inherent safety factor. However, all local anesthetics have the potential for systemic toxicity with either inadvertent intra-arterial injection or use of excessive amounts of drug. Toxic symptoms range from mild, such as as tinnitus, to more severe, such as convulsions, and further progression to cardiovascular collapse. This toxicity must be anticipated and treated appropriately. Our own institutional study showed an 89% success rate with axillary brachial plexus blocks used for hand and wrist procedures. However, the success rate dropped to 60% for surgery involving the elbow. These results were improved by the use of local anesthetic supplementation or intravenous sedation.

A common epineural sheath for the nerves in the popliteal fossa and its possible implications for sciatic nerve block.

Sciatic nerve block in the popliteal fossa is associated with a highly variable success rate. Frequently, anesthesia is profound in the distribution of both the tibial (TN) and common peroneal nerves (CPN), although the response to nerve stimulation or paresthesia is obtained in the distribution of one division of the nerve. However, anesthesia in the distribution of only one division of the nerve is also a common occurrence under apparently identical clinical circumstances. Looking for a possible role of a common epineural sheath in these phenomena, we injected dye into the epineural sheath of the tibial nerve in 10 cadaver legs and observed its spread within the sheath. Injections of 15 mL and 30 mL of the dye resulted in a proximal spread of 147 +/- 34 mm and 172 +/- 50 mm, respectively, from the injection point 10 cm below the popliteal fossa crease. In a majority of the legs, the dye reached the division of the sciatic nerve in the popliteal fossa, bathing both the TN and CPN. Gross inspection and histologic examination of the sciatic nerve specimens revealed a common epineural sheath enveloping the TN and CPN. The presence of the common epineural sheath and its characteristics may have important clinical implications for sciatic nerve blockade in the popliteal fossa.

Characterization of an Arabidopsis Mutant That Is Nonresponsive to Inducers of Systemic Acquired Resistance.

Systemic acquired resistance (SAR) is a general defense response in plants that is characterized by the expression of pathogenesis-related (PR) genes. SAR can be induced after a hypersensitive response to an avirulent pathogen or by treatment with either salicylic acid (SA) or 2,6-dichloroisonicotinic acid (INA). To dissect the signal transduction pathway of SAR, we isolated an Arabidopsis mutant that lacks the expression of an SA-, INA-, and pathogen-responsive chimeric reporter gene composed of the 5[prime] untranslated region of an Arabidopsis PR gene, [beta]-1,3-glucanase (BGL2), and the coding region of [beta]-glucuronidase (GUS). This mutant, npr1 (nonexpresser of PR genes), carries a single recessive mutation that abolishes the SAR-responsive expression of other PR genes as well. While SA-, INA-, or avirulent pathogen-induced SAR protects wild-type plants from Pseudomonas syringae infection, the mutant cannot be protected by pretreatment with these inducers. The insensitivity of npr1 to SA, INA, and avirulent pathogens in SAR induction indicates that these inducers share a common signal transduction pathway. Moreover, in npr1, the localized expression of PR genes induced by a virulent Pseudomonas pathogen is disrupted, and the lesion formed is less confined. These results suggest a role for PR genes in preventing the proximal spread of pathogens in addition to their suggested role in SAR.

Pancoast syndrome: An unusual presentation of adenoid cystic carcinoma : Jatton MQF, Allen MB, Cooke NJ. Belvidere Hospital, London Rd, Glasgow. Eur Respir J 1993;6:271–272

We report on a patient with primary pulmonary adenoid cystic carcinoma presenting with Pancoast syndrome. Pancoast syndrome has not previously been described with this tumour. Other unusual features of this case include the peripheral origin and mediastinal involvement, with lack of proximal endobronchial spread.

CLINICAL AND RADIOLOGICAL COMPARISON OF PERIVASCULAR AND TRANSARTERIAL TECHNIQUES OF AXILLARY BRACHIAL PLEXUS BLOCK

The perivascular technique of axillary brachial plexus block results in incomplete block of radial and musculocutaneous nerves in 10-20% of patients. With the transarterial technique and a large dose of mepivacaine, success rates of 99% have been reported. We have compared the clinical efficacy of these techniques in 50 patients using 1% mepivacaine 45 ml with adrenaline. If required, the block was supplemented with additional blocks of single nerves or i.v. alfentanil. Additionally, eight patients in each group were studied with computed tomography after contrast medium was added to 0.5% bupivacaine 40 ml. There were no statistically significant differences in sensory or motor block between the groups at 20 min or in the plasma concentrations of mepivacaine measured 0-45 min after injection. In the CT scans, both proximal and distal spread of the contrast medium were more common after perivascular than after transarterial block. The distribution of the contrast medium was not related to the efficacy of the block.

Pancoast syndrome: an unusual presentation of adenoid cystic carcinoma

We report on a patient with primary pulmonary adenoid cystic carcinoma presenting with Pancoast syndrome. Pancoast syndrome has not previously been described with this tumour. Other unusual features of this case include the peripheral origin and mediastinal involvement, with lack of proximal endobronchial spread.

The efficacy of tourniquets as a first-aid measure for Russell's viper bites in Burma

The efficacy of the tourniquets commonly used by Russell's viper bite victims in retarding venom movement from the bite was studied in 37 cases by measuring venom antigen levels by enzyme-linked immunosorbent assay in venous samples taken proximal and distal to the tourniquets and also before and after release of tourniquets. In most cases, the tourniquet did not prevent proximal spread of venom. In 8 37 cases, however, venom antigen assays suggested but did not prove that venom absorption was being delayed by the tourniquet.

Factors affecting transfer and spread of Phellinusweirii mycelium in roots of second-growth Douglas-fir

Effects of site, root diameter, soil depth of interroot contact, length of root surface in contact, type of contact, and relative position of roots were investigated on the frequency of transfer of Phellinusweirii (Murr.) Gilbertson mycelium between roots and its spread along roots of second-growth Douglas-fir (Pseudotsugamenziesii (Mirb.) Franco). Successful transfer of P. weirii as ectotrophic or endotrophic mycelium occurred in 32 and 3%, respectively, of total number of interroot contacts. Unsuccessful transfers occurred in 4 and 62%, respectively, with the balance of contacts having undetermined transfers, owing to extension of mycelium to the root collar of both roots in contact. A Pseudotsuga–Polystichum site had a higher frequency of unsuccessful transfer than two Pseudotsuga–Gaultheria sites. Average root diameter was greater and average depth was less in contacts with successful transfers than in those with unsuccessful transfers. Type or length of contact or relative position of roots had no significant effects on transfers. There was a highly significant inverse relationship between root diameter and length of endotrophic mycelial spread as measured by decay column. The regression of endotrophic on ectotrophic mycelial spread along roots was highly significant for both proximal and distal spread. In most roots, ectotrophic mycelium had spread distally to the tip and proximally to the stump, whereas endotrophic mycelium had not.