Magnetic Stent Removal in a Nurse Led Clinic; a Nine Month Experience.

Ureteric stents are frequently inserted post endourological procedures. However, subsequent endoscopic stent removal requires a second procedure for the patient and the availability of necessary resources. Longer duration of indwelling stents can lead to increased risk of symptoms and complications. The use of magnetic stents removed with a magnetic retrieval device (BlackStar©), offers an alternative which obviates the need for cystoscopy. We assessed the outcomes for this novel method of stent removal in our institution. A retrospective analysis was performed of all patients undergoing magnetic stent insertion and subsequent removal in a nurse-led clinic over a nine-month period. Patients were followed up with a prospective validated Ureteral Stent Symptoms Questionnaire (USSQ)3. A cost analysis was also performed. In total, 59 patients were treated using magnetic stents. The complication rate was low (6.7%). The median duration of indwelling stent was 5.8 days (range 1-11 days). Patients reported haematuria and lower urinary tract symptoms but >90% experienced no functional impairment with minimal days of employment lost (mean 0.75 days). All patients reported satisfaction with nurse-led stent removal and 97% were happy to have stents removed via this method in the future. The total financial savings were estimated at €47,790 over this period. Nurse-led removal of magnetic stents is safe and well tolerated by patients and enables expedient stent removal. It also provides a significant cost benefit and frees up valuable endoscopic resources.

A rare case of recurrent urachal adenocarcinoma of the bladder.

Urachal carcinoma is a rare, aggressive malignancy accounting for less than 1% of bladder neoplasms. These tumours are usually adenocarcinomas and occur at the dome or anterior wall of the bladder. They often escape early clinical detection, growing for prolonged periods prior to diagnosis, resulting in local invasion and systemic spread before therapeutic intervention is initiated. We present the case of a recurrent urachal carcinoma in a young female.

Laparoscopic nephrectomy: initial experience with 120 cases.

Laparoscopic nephrectomy for both benign and malignant diseases of kidney is increasingly being performed. We report our experience with the first 120 consecutive laparoscopic nephrectomy performed in our hospital. It is the retrospective analysis of a prospectively maintained database of 4 years period. The parameters examined included age, gender, indications, operative time, blood loss, intraoperative and post operative complications. Mean age of surgery was 59 years (rang 19-84years). The indications for surgery included solid renal masses (71 patients), non-functioning kidneys (43), and collecting system tumours (6). The mean operating time was 132 minutes (range 75-270), average blood loss was 209 ml (range 0-1090) and average hospital stay was 4.7days (range 2-20). Bleeding, bowel injury and poor progression of laparoscopic procedure were the reasons in 7 (5.8%) cases converted to open surgery. There was 1 (0.8%) perioperative mortality. Eight (6.6%) patients developed post operative complications. Laparoscopic nephrectomy has inherent benefits and may be considered an alternate therapeutic option for kidney diseases with acceptable morbidity

Laparoscopic pyeloplasty.

We report our results and short term follow up of transperitoneal laparoscopic pyeloplasty for pelvi-ureteric junction (PUJ) obstruction. We have prospectively maintained a database to document our initial experience of 54 laparoscopic pyeloplasty. All procedures were carried out by one surgeon through a transperitoneal approach. The data extends from April 2005 to September 2008 and reports operative time, blood loss, complications, hospital stay, short term follow-up on symptomatic and radiological outcome. Fifty-four procedures were performed during the study period. Mean patient age was 29 years. Mean operating time was 133 minutes (range 65-300 minutes), and mean blood loss was 45 ml (range 20-300 ml). No intra operative complication occurred. Neither blood transfusion nor conversion to open surgery was required. Postoperative mean hospital stay was 3.4 days (range 3-14 days). There were 3 anastomotic leakages; 2 in the immediate postoperative period and 1 following removal of stent. They all required percutaneous drainage and prolonged stenting. Overall 47 (87%) patients have symptomatic relief and resolution of obstruction on renogram. Four (7%) patients developed recurrence. Three (5.5%) patients had symptomatic relief but have a persistent obstructive renogram. Laparoscopic pyeloplasty is an effective alternative treatment for symptomatic pelvi-ureteric junction obstruction. The results appear comparable to open pyeloplasty with decreased postoperative morbidity.

Impact of volume guarantee ventilation on arterial carbon dioxide tension in newborn infants: a randomised controlled trial.

OBJECTIVE: To compare the effects of the two modes of ventilation, synchronous intermittent positive pressure ventilation (SIPPV) and SIPPV with Volume Guarantee (VG), on arterial carbon dioxide tension (PaCO(2)) immediately after neonatal unit admission. STUDY DESIGN: Randomised study of ventilation mode for premature inborn infants admitted to two tertiary neonatal units. After admission, infants were randomised to receive either SIPPV or VG using a Dräger Babylog 8000 plus ventilator. In the SIPPV group, peak airway pressure was set clinically. In the VG group, desired tidal volume was set at 4 ml/kg, with the ventilator adjusting peak inspiratory pressure to deliver this volume. The study was completed once the first arterial PaCO(2) was available, with the desirable range defined as 5-7 kPa. RESULTS: PaCO(2) was significantly higher in the VG group (VG: 5.7 kPa, SIPPV: 4.9 kPa; p=0.03). The VG group had fewer out-of-range PaCO(2) values (VG: 42%, SIPPV: 57%) and fewer instances of hypocarbia <5 kPa (VG: 32%, SIPPV: 57%) but neither difference achieved statistical significance. Regression analysis showed PaCO(2) was negatively correlated with gestation (r=-0.41, p=0.01) and also with the mode of ventilation (r=0.32, p<0.05). In the VG group, all infants 23-25 weeks' gestation had out-of-range PaCO(2) values. VG significantly reduced the incidence of out-of-range PaCO(2) and hypocarbia in infants over 25 weeks' gestation (VG: 27%, SIPPV: 61%; p<0.05). CONCLUSION: Using this strategy, VG appears feasible in the initial stabilisation of infants over 25 weeks' gestation, with a halving of the incidence of hypocarbia. In the small number of babies studied below this gestation, VG was not found to be effective.

A dose response study of inhaled nitric oxide in hypoxic respiratory failure in preterm infants.

BACKGROUND: Inhaled nitric oxide (iNO) is used widely in newborn infants with hypoxic respiratory failure, despite the known and theoretical toxicity of iNO, and a relative lack of information about appropriate doses. AIM: To determine whether a dose-response relationship existed for iNO in preterm infants. DESIGN: A four-period, four-dose, cross-over design was used with iNO given for 15 min in a randomised sequence in concentrations of 5, 10, 20 and 40 parts per million (ppm), with a minimum 5 min wash-out period. Data on ventilatory, blood gas and other physiological measurements were recorded before and at the end of each period. The relationship of clinical response with iNO dose and period was analysed using multivariate regression. SUBJECTS: Infants with gestational age < 34 weeks and < 28 days postnatal age with hypoxic respiratory failure were recruited. OUTCOME MEASURE: A clinically significant dose-response was defined as a rise in the post-ductal arterial oxygen tension (PaO(2)) of at least 3 kPa. RESULTS: Thirteen infants were recruited. At trial entry, ten were < 3 days of age; 11 were being treated with high frequency oscillatory ventilation; median (inter-quartile range) gestational age 27 (25-29) weeks; birthweight 983 (765-1120) g; oxygenation index 27.1 (21.8-28.8). Six infants (46%) showed a clinically significant response. After adjusting for period and patient effect, no evidence for an overall dose effect was identified (likelihood ratio test, p=0.34). CONCLUSION: No evidence of a dose-response relationship with iNO was found in this study of very preterm infants with respiratory failure.

Use of nasal continuous positive airway pressure during neonatal transfers.

OBJECTIVE: To review all cases in which nasal continuous positive airway pressure (CPAP) was used as a means of respiratory support during land based ambulance transfers by a regional neonatal transport service. DESIGN: Retrospective study based on review of transport records. RESULTS: A total of 1175 transfer requests were received over the 21 month period. The infant in 163 of these cases was receiving nasal CPAP. Ninety two referrals were accepted by the doctor/nurse practitioner led team. Of these, 84 were transported while receiving nasal CPAP. Intervention during transport was required in three of these cases. Fifty five referrals were accepted by the nurse led team. Of these, 16 were transported while receiving nasal CPAP. Intervention was required in two cases. CONCLUSION: There is a small but significant demand for transferring infants who are receiving nasal CPAP. Nasal CPAP appears to be a safe method of respiratory support for a carefully selected group of infants during land based ambulance transfers.

A simple tool for rapid access to a symptomatic breast clinic.

AIM: The introduction of a rapid referral system has led to an increase in the number of patients with benign disease using clinic appointments. This situation could delay those patients, who do have cancer but are not referred within these rapid referral guidelines. Existing guidelines fail to benefit those patients with lower risk symptoms. We reviewed prospective audit data from patients referred to a symptomatic breast unit with the aim of introducing a referral schema based upon symptoms, age and relative risk of cancer. METHOD: Demographic details, mode of referral, history and presenting symptoms were collected from each of the 2064 patients referred to the James Cook University Hospital (JCUH) breast unit from April 2001 to March 2002. RESULTS: Odds Ratios (OR) from eight dependent variables gave a 30% improvement in prediction accuracy of breast cancer. From these findings a breast referral schema is presented that is designed to expedite referral from primary care of those patients most at risk. CONCLUSIONS: Use of the schema within primary care could lead to an increase in the early referral of patients with breast cancer.

Feasibility of tidal volume-guided ventilation in newborn infants: a randomized, crossover trial using the volume guarantee modality.

BACKGROUND AND AIM: Volume guarantee (VG) is a new composite mode of pressure-limited ventilation, available on the Dräger Babylog 8000 ventilator, which allows the clinician to set a target mean tidal volume to be delivered while still maintaining control over peak airway pressures. This study aimed to investigate the feasibility and efficacy of this mode of ventilation in premature newborn infants with respiratory distress syndrome (RDS). METHODS: Two groups of infants were studied: those receiving synchronized intermittent positive pressure ventilation (SIPPV) in early phase of RDS (group 1) and those in recovery phase of RDS being weaned from artificial ventilation through synchronized intermittent mandatory ventilation (SIMV; group 2). Both groups of infants were studied over a 4-hour period. Before the start of the study, the infants were either receiving SIPPV (group 1) or SIMV (group 2). Infants in group 1 were randomized to either continue on SIPPV for the first hour of the study or to receive SIPPV plus VG for the first hour. Subsequently, the 2 modes were used alternately for the remaining three 1-hour periods. Similarly, infants in group 2 were randomized to either continue on SIMV for the first hour of the study or to receive SIMV plus VG for the first hour. Data on ventilation parameters and transcutaneous carbon dioxide and oxygen were collected continuously. RESULTS: Forty infants were studied, 20 in each group. The mean (standard error) gestational age was 27.9 (0.3) weeks; birth weight was 1064 (60) g. No adverse events were observed during the study. Fractional inspired oxygen during SIMV plus VG was 0.31 (0.3); during SIMV, 0.31 (0.3); during SIPPV plus VG, 0.41 (0.4); and during SIPPV, 0.40 (0.4). Transcutaneous carbon dioxide pressure during SIMV plus VG was 6.0 (2.2) kPa; during SIMV, 5.9 (2.2) kPa; during SIPPV plus VG, 6.4 (2.9) kPa; and during SIPPV, 6.4 (2.8) kPa. Transcutaneous partial pressure of oxygen during SIMV plus VG was 8.4 (8.7) kPa; during SIMV, 8.6 (8.8) kPa; during SIPPV plus VG, 7.6 (4.0) kPa; and during SIPPV, 7.7 (4.2) kPa. None of these differences was statistically significant. The mean (standard error) peak inspiratory pressure used during SIMV was 17.1 (3.4) cm of water; during SIMV plus VG, 15.0 (7.5) cm of water; during SIPPV plus VG, 17.1 (9.3) cm of water; and during SIPPV, 18.7 (8.3) cm of water. The mean airway pressure during SIMV plus VG was 6.5 (3.1) cm of water; during SIMV, 6.9 (2.8) cm of water; during SIPPV plus VG, 9.6 (4.5) cm of water; and during SIPPV, 9.8 (4.6) cm of water. CONCLUSION: VG seems to be a stable and feasible ventilation mode for neonatal patients and can achieve equivalent gas exchange using statistically significant lower peak airway pressures both during early and recovery stages of RDS.ventilation, airway pressure, volume guarantee, tidal volume.

Effect of chronic excess of tumour necrosis factor-alpha on contractile proteins in rat skeletal muscle.

The effect of chronic tumour necrosis factor-alpha (TNF-alpha) treatment on the synthesis of specific myofibrillar proteins such as heavy chain myosin, light chain myosin and G-actin in rat diaphragm were evaluated. Muscles (diaphragm) from control and experimental groups (TNF-alpha i.v. at 50 microg/kg body wt for 5 days) were incubated in the presence of 35S-methionine for 2 h. Myofibrillar protein extracts were prepared and protein was electrophoresed on sodium dodecyl sulphate-polyacrylamide gels. Heavy chain myosin, light chain myosin and G-actin were identified by Western blot analysis using specific monoclonal antibodies. Polyacrylamide gel electrophoresis (PAGE) followed by Western blot analysis revealed two types of heavy chain myosin (206 and 212 kD), all four types of light chain myosin (15, 16.5, 18 and 20 kD) and a single type of G-actin (42 kD). Chronic TNF-alpha treatment produced a significant decline in the synthesis of all types of myofibrillar proteins, namely heavy chain myosin, light chain myosin and G-actin. TNF-alpha impaired peptide-chain initiation in diaphragm muscle which was reversed by the branched-chain amino acids (BCAA) therapy of TNF-alpha treated rats. These findings indicate a significant role for TNF-alpha in the translational regulation of protein synthesis in skeletal muscle.

Effect of tumour necrosis factor-alpha on total myofibrillar and sarcoplasmic protein synthesis and polysomal aggregation in rat skeletal muscles.

The total sarcoplasmic and myofibrillar protein synthesis was reduced in incubated fast-twitch extensor digitorum longus (EDL) and slow-twitch soleus of rat after in vivo tumour necrosis factor-alpha treatment at 50 micrograms/kg/day for 5 days. The rate of protein synthesis in the myofibrillar fraction was inhibited more severely (41% in EDL and 34% in soleus) than that in the sarcoplasmic fraction (23% in EDL and 14% in soleus). Sucrose density gradient centrifugation analysis indicated that TNF-alpha treatment impaired polysomal aggregation in rat diaphragm muscle. Compared with the control muscles, the ratio of 40S and 60S subunits to polysomes was higher in TNF-alpha treated muscles. These findings suggest a role for TNF-alpha in the translational regulation of protein synthesis in rat skeletal muscle.

Use of permissive hypercapnia in the ventilation of infants with respiratory syncytial virus infection.

UNLABELLED: We wished to retrospectively evaluate the effects of permissive hypercapnia (PHY) on barotrauma, mortality and length of stay when applied to ventilated infants with respiratory syncytial virus (RSV) bronchiolitis. Nineteen control infants with RSV induced respiratory failure were treated with conventional ventilation (April 1991-January 1994), after which time PHY was adopted as unit policy. A further 28 infants were then treated with PHY (January 1994 April 1996). Demographic and physiological data were collected from admission, and outcome variables including length of stay, barotrauma and mortality were recorded. The PHY group showed a significantly higher mean pCO2 (7.6 vs 5.2 kPa), a lower mean pH (7.34 vs 7.40), and a reduction in maximal peak inspiratory pressures (25 vs 30 cmH2O). Mortality, barotrauma, use of neuromuscular blockade and nosocomial infection did not differ between groups. There was a trend towards increased length of ventilation in the PHY group (median 7 vs 5 days). CONCLUSION: Based on this retrospective data we can show no benefit for the use of permissive hypercapnia as a ventilatory strategy in this patient group. A prospective randomised controlled trial is warranted to accurately assess the outcome variables and cost implications of this strategy.

The effect of histone-mRNA interaction in protein synthesis.

The effect of lysine-rich and arginine-rich histones on selective inhibition of translation of mRNAs of tobacco mosaic virus (TMV), brome mosaic virus (BMV) and luciferase, in rabbit reticulocyte (RRL) was evaluated. Nuclease-treated RRL were supplemented with an appropriate mRNA and incubated with lysine-rich or arginine-rich histones at 5 and 2.5 micrograms/100 microliters lysate at 30 degrees C. Protein synthesis was measured as incorporation of 3H-leucine into protein for 24 min. The lysine-rich histone was more inhibitory than arginine-rich histone. At 5 and 2.5 micrograms/100 microliters lysate concentration, the lysine-rich histone inhibited translation of TMV mRNA by 57% and 35%, respectively, after 24 min. The corresponding values for arginine-rich histone were 31% and 13%. Both histones had a more inhibitory effect on the translation of viral mRNA than luciferase mRNA. Arginine-rich histone at 2.5 micrograms/100 microliters lysate did not cause any inhibition of luciferase mRNA. The spectrophotometric analysis of histone-mRNA mixtures at 280 nm indicated that, compared with arginine-rich histone, lysine-rich histone had a stronger affinity for mRNA.

Effect of glucocorticoids on tumor necrosis factor induced suppression of protein synthesis in rat aortic smooth muscle: comparison with extensor digitorum longus.

Protein synthesis was measured in incubated aortic smooth muscle and fast-twitch extensor digitorum longus (EDL) in both sham operated and adrenalectomized (ADX) rats. The studies were performed on four groups: a) untreated controls; b) rats treated with tumor necrosis factor (TNF) @ 50 micrograms/kg. b.w.; c) rats treated with cortisone @ 100 mg/kg/day for 5 days; or d) rats treated with cortisone plus TNF. Both TNF and cortisone suppressed protein synthesis in the aortic smooth muscle and EDL in intact animals. TNF given together with cortisone, induced a significant additional decrease in protein synthesis in both muscle types as compared to cortisone-treated rats. The rate of protein synthesis in aortic smooth muscle from sham operated rats was control > TNF > cortisone > Cortisone+TNF; in the case of EDL, rate was control > cortisone > TNF > Cortisone+TNF. In ADX animals, TNF alone did not affect protein synthesis in both aortic smooth muscle and EDL. Though cortisone alone produced a significant inhibition of protein synthesis, there was no significant further decline in protein synthesis when cortisone was given together with TNF. These findings suggest that the inhibitory effect of TNF on muscle protein synthesis is mediated through glucocorticoids.

Effect of fasting, branched-chain amino acids, and glucocorticoids on histone H1 extractability from rat skeletal muscle.

The effect of 72 h fasting, nutritional therapy of fasted rats, and acute and chronic glucocorticoid treatment on the yield of histone H1 from rat hind limb muscles was determined. Fasting significantly enhanced the extractability of muscle H1. The effect of treating starved rats with glucose alone, or with glucose supplemented with branched-chain amino acids (BCAA), or with two commercial preparations of mixtures of essential and non-essential amino acids was evaluated. Treatment of starved rats with glucose alone significantly decreased H1 extractability from muscles, but isocaloric treatment with glucose supplemented with BCAA or two commercial preparations of amino acid mixtures was more effective. Glucocorticoid treatment for 5 days enhanced the yield of H1 from muscles less than starvation. The enhanced H1 extractability from muscles noted in starved rats is similar to that reported in rats with insulinopenic diabetes and may reflect changes in nuclear fragility.

Effect of parvalbumin and S-100 protein on protein synthesis in rabbit reticulocyte lysate.

The effect of two high affinity Ca+ binding acidic proteins, parvalbumin and S-100 protein on protein synthesis in rabbit reticulocyte lysates (RRL), was investigated. Nuclease-treated RRL, supplemented with yeast mRNA, and 3H-leucine were incubated at 37 degrees C, and incorporation of 3H-leucine into protein was determined for 24 min. At 20 micrograms/100 microliters lysate concentration, both parvalbumin and S-100 protein caused a marked inhibition of protein synthesis compared with the control lysate. At a lower concentration parvalbumin was less inhibitory than histone H1; the effect of S-100 protein was not significant. The combined inhibitory effect of parvalbumin and H1 was not additive probably due to strong interaction between them as was evidenced by the enhanced absorbance of parvalbumin-H1 mixture. Spectrophotometric profiles of parvalbumin-tRNA mixture indicated that, unlike H1, parvalbumin did not inhibit protein synthesis by binding with nucleic acids. These results suggest an important role for parvalbumin in translational regulation.

A translational inhibitor from muscles of diabetic rats: identification as histone H1.

A heat- and acid-stable protein fraction that inhibited peptide chain initiation in rabbit reticulocyte lysates was extracted from frozen, powdered rat skeletal muscles by stepwise trichloroacetic acid precipitation. Streptozotocin-induced diabetes increased the inhibitory activity; this was prevented by insulin therapy. Size-exclusion high-performance liquid chromatography resolved four inhibitory fractions; only one was consistently increased (approximately 2-fold) in muscle extracts from diabetic rats. Polysome profiles of lysates incubated with this fraction indicated peptide chain initiation inhibition. On sodium dodecyl sulfate-polyacrylamide gel electrophoresis the purified inhibitory fraction migrated with apparent Mr 30 and 32 kDa, which on Western blot immunostained with antisera against histone H1/H1(0). Perchloric acid extraction of muscle homogenates yielded approximately twofold more H1 from diabetic than from control rats; yield from diabetics decreased to control values 5 h after subcutaneous insulin injection. Inclusion of detergent during homogenization increased H1 yield more from muscles of control than from diabetic rats and abolished the difference between them. Because H1 affects several biochemical reactions, its facilitated extraction from insulin-deprived tissues can bias interpretation of studies of insulin action.

Histone-H1 inhibits translation by reticulocyte lysates with relative mRNA selectivity.

Histone-H1 purified from rat skeletal muscle is a relatively potent inhibitor of peptide chain initiation in a cell free system, the rabbit reticulocyte lysate (50% inhibition at approximately 0.4 microM). H1 does not inhibit formation of the ternary complex nor its attachment to 40S ribosomes; the data are compatible with H1 binding to mRNA. The inhibition shows mRNA selectivity: translation of beta-globin mRNA is more affected than that of alpha-globin mRNA and hepatic albumin mRNA more than total hepatic mRNA. Whether or not histone-H1 plays a role in translational regulation in intact cells is conjectural, it may serve as a useful model for protein-mRNA interactions.