The Birmingham experience of high-pressure methylene blue dye test during primary and revisional bariatric surgery: A retrospective cohort study.

INTRODUCTION: Leak following bariatric surgery continues to be associated with morbidity and rarely mortality. With improvement in surgical techniques and stapler design, leak rates have reduced drastically. Intra-operative high pressure Methylene blue leak test (HPMB) is one of the techniques employed to confirm integrity of anastomoses and staple lines. Despite this, evidence for its use remains limited. We evaluated the role of HPMB in detecting and preventing leaks. METHODS: A retrospective cohort of consecutive patients who underwent primary or revisional Laparoscopic Sleeve Gastrectomy (SG) or Laparoscopic Roux-en-Y Gastric bypass (RYGB) under the care of five surgeons in three centres across Birmingham, UK, between 2012 and 2016 were assessed. All patients had routine HPMB at the end of the procedure. Demographics, HPMB positivity, and post operative leaks were recorded. RESULTS: 924 patients underwent bariatric surgery: 696(75.3%) RYGB, and 225(24.3%) SG. 85(9.2%) were revisional procedures. Two HPMB were positive, which necessitated staple or suture line reinforcement with sutures intra-operatively. The patients had an uneventful recovery. 5 patients had postoperative leaks, all of whom had negative intraoperative HPMB: 3 SG patients; and 2 RYGB patients (gastro-jejunostomy anastomotic leaks). There was no statistically significant relationship between positive HPMB and anastomotic leak (Fishers exact test; p = 1). CONCLUSION: Despite routine use of methylene blue dye test in 924 patients, there were only two positive tests. Whilst HPMB may demonstrate technical failure, this study suggests that there is no role for its routine use in primary bariatric surgery. Discontinuation of this practice would reduce risk of anaphylaxis to the dye, cost, and intra-operative time.

Day surgery for achalasia cardia: Time for consensus?

INTRODUCTION: Laparoscopic Heller's myotomy (LHM) is the most effective therapy for achalasia of the oesophagus. Most case series of LHM report a length of hospital stay (LOS) >1 day. We present 14 years of experience of LHM to examine the safety and feasibility of LHM as a day case procedure. METHODS: We retrospectively examined patients undergoing elective LHM for achalasia at our institution between 2000 and 2014. Demographics, episode statistics, prior investigations and interventions were collated. Outcomes, including LOS, complications and re-interventions, were compared for the periods before and after a consensus decision at our institution in 2008 to perform LHM as a day case procedure. RESULTS: Sixty patients with a mean age of 41 ± 13 years were included, of whom 58% were male. The median LOS for all patients was 1 day (interquartile range [IQR] 0-2.25). Overall, LHM was performed as a day case in 27 (45%) cases, at 2/26 (7.7%) in the first period versus 25/34 (73.5%) in the second (p<0.01). There were no significant differences in age, gender or previous interventions between day surgery and non-day surgery groups. One patient required subsequent unplanned surgery, while six (10%) needed endoscopic treatment of recurrent symptoms within 12 months. CONCLUSIONS: LHM can be performed safely as a day case procedure. Complication rates are low, with only a small proportion of patients requiring endoscopic treatment for symptom recurrence within 1 year.

Pseudomonas, Pantoea and Cupriavidus isolates induce calcium carbonate precipitation for biorestoration of ornamental stone.

AIMS: Bacterially induced calcium carbonate precipitation from various isolates was investigated aiming at developing an environmentally friendly technique for ornamental stone protection and restoration. METHODS AND RESULTS: Micro-organisms isolated from stone samples and identified using 16S rDNA and biochemical tests promoted calcium carbonate precipitation in solid and novel liquid growth media. Biomineral morphology was studied on marble samples with scanning electron microscopy. Most isolates demonstrated specimen weight increase, covering partially or even completely the marble surfaces mainly with vaterite. The conditions under which vaterite precipitated and its stability throughout the experimental runs are presented. CONCLUSIONS: A growth medium that facilitated bacterial growth of different species and promoted biomineralization was formulated. Most isolates induced biomineralization of CaCO3 . Micro-organisms may actually be a milestone in the investigation of vaterite formation facilitating our understanding of geomicrobiological interactions. Pseudomonas, Pantoea and Cupriavidus strains could be candidates for bioconsolidation of ornamental stone protection. SIGNIFICANCE AND IMPACT OF THE STUDY: Characterization of biomineralization capacity of different bacterial species improves understanding of the bacterially induced mineralization processes and enriches the list of candidates for biorestoration applications. Knowledge of biomineral morphology assists in differentiating mineral from biologically induced precipitates.

[Laparoscopic sleeve gastric resection: experience of Bariatric Department in University of Cyprus, Greece].

Experience of laparoscopic sleeve gastric resection performance for morbid obesity was summarized. Indications for the method application, the operation procedure details, its mechanism of action, securing the body mass reduction, are adduced. The efficacy and security of the intervention were estimated.

Evaluation of the performance of Trima Accel® v5.2 for the collection of concentrated high-dose platelet products and concurrent plasma from high platelet count donors, in Germany.

BACKGROUND AND OBJECTIVES: This study was undertaken to test the ability of Trima Accel® version 5.2 to simultaneously collect concentrated high-dose leukoreduced platelet products and double doses of plasma. MATERIALS AND METHODS: Random volunteers (18-65 years of age) with preprocedure platelet counts above 270 × 10(3) /µl were recruited among the blood center's apheresis donors. All complied with the center's donor selection criteria. RESULTS: One hundred fourteen (114) collections were performed. Depending on which definition of single platelet dose is used (2.0 × 10(11) as prevalent standard in most European countries, and 3.0 × 10(11) as prevalent standard in the United States and Canada) in 107/114 (single dose = 2.0 × 10(11) ) and 39/114 (single dose = 3.0 × 10(11) ) instances, a triple platelet product was obtained. In 87 cases (76%), a double plasmaproduct (>430 ml) was collected, and in seven cases (6%), a single plasma product (>220 ml) was collected. In 20 procedures, only platelets without concurrent plasma were collected (18%). Overall procedure time was 87 ± 13 min and average platelet yield per procedure was 8.5 ± 1.4 × 10(11) (final storage concentration, 1,279 ± 153 × 10(3) /µl). The median residual leukocyte content per transfusion dose was 0.13 × 10(6) (0.02-0.98 × 10(6) ) for a single dose of 2.0 × 10(11) and 0.14 × 10(6) (0.02-0.98 × 10(6) ) for a single dose of 3.0 × 10(11) . CONCLUSIONS: Trima Accel® version 5.2 allows for collection of concentrated high yield platelet products. It offers high productivity and reliably achieves the configured yield targets. Leukoreduction performance complied with both US and EU legal requirements. Collection as hyperconcentrates furthermore allowed for concurrent collection of double dose plasma in the majority of the procedures.

Assessment of the effect of surgery on the kinetics of circulating tumour cells in patients with operable breast cancer based on cytokeratin-19 mRNA detection.

AIMS: The aim of this study was to evaluate the effect of surgery on the kinetics of CTCs in breast cancer patients. METHODS: The detection of CK-19 mRNA-positive CTCs in the blood by RT-PCR was analysed in 104 stage 0-IIIA patients at 4 time-points: prior to surgery, upon completion, 24 h after surgery and 15 days after surgery. Furthermore, a late sample was assessed prior to initiation of adjuvant chemotherapy in a subgroup of 53 patients. As negative controls, peripheral blood was obtained from 50 female patients undergoing excision of benign breast lesions and from 11 female patients receiving surgery for early-stage colorectal cancer. RESULTS: A significant percentage of blood samples from breast cancer patients (14.4%) were negative for CK-19 preoperatively but turned transiently positive early postoperatively. However, no significant difference in CK-19 mRNA detection was noted among the first 4 examined time-points. There was no significant correlation between CK-19 mRNA-positive cells and classic prognostic factors. A significant increase in CK-19 mRNA-positivity (32.1%) was observed in a late sample of the subgroup of 53 patients before adjuvant chemotherapy after a median of 54 days, postoperatively. CONCLUSIONS: Surgery may result in CTC detection in a small proportion of early breast cancer patients. There is no clear correlation to indicate which patients are expected to have detectable CTCs. Although CTCs are detected in a small proportion of patients during the perioperative period, the detection rate may increase over time and with longer follow-up.

A novel HLA-B allele, B*14:10, identified by haplotype-specific sequencing.

A novel HLA-B allele, HLA-B*14:10, differs from HLA-B*14:08 by three nucleic acid substitutions.

A novel HLA-C allele, HLA-Cw*06:20.

A novel HLA-C allele, HLA-Cw*06:20 differs from HLA-Cw*06:02 by one nucleotide exchange.

Identification of a novel HLA-B51 allele, HLA-B*51:94.

A novel HLA-B*51:94 allele differs from HLA-51:01 by a nucleotide exchange in exon 3.

Adipose tissue fatty acids in breast cancer patients versus healthy control women from Crete.

BACKGROUND: Few studies have implemented biomarkers of fatty acid intake in relation to breast cancer. AIMS: To examine possible differences in adipose tissue fatty acid composition between breast cancer patients and healthy control women. The relationship between tumor promotion and adipose tissue fatty acid synthesis was also investigated. METHODS: The study was conducted at the University of Crete. Subjects included 94 women with clinically diagnosed cancer of the breast and 131 healthy control women. Histological tumor grading and breast cancer staging were assessed. Fatty acids were determined by gas chromatography in gluteal adipose tissue. RESULTS: Conditional logistic regression analysis controlling for potential confounders indicated that elevated adipose monounsaturated fatty acids and oleic acid are associated with reduced odds of breast cancer [OR (T2 vs. T1) 0.15; 95% CI 0.03-0.64, and OR (T2 vs. T1) 0.18; 95% CI 0.04-0.71, respectively]. Adipose myristic acid was associated with an increase in breast cancer risk [OR (T3 vs. T1) 5.66; 95% CI 1.3-23.9]. CONCLUSIONS: Adipose oleic acid is inversely related, whereas adipose myristic acid is positively related to breast cancer risk. These relations could be mediated by Her-2/neu and FAS oncogenes.

Trisomy 19 as the sole chromosomal abnormality in proliferative chronic myelomonocytic leukemia.

Distinct morphologic and clinical features associated with specific chromosomal abnormalities have been described in subgroups of myelodysplastic syndromes (MDS), which often are losses or gains and only rarely translocations. Among 103 consecutive MDS patients diagnosed and karyotyped at the Albert-Ludwigs University of Freiburg (ALU) between 1993 and 1999, two chronic myelomonocytic leukemias (CMMoL) displayed trisomy 19 (+19) as the sole chromosomal abnormality. Three further CMMoL cases with +19 as the single abnormality, two of which previously reported, were collected from other centers. Four of the five patients presented with leukocytosis and splenomegaly, and an increased number of ringed sideroblasts was observed in two cases. Treatment was low-dose Decitabine (cases 1 and 2), oral steroids (case 3), hydroxyurea (case 4), and daunorubicin/Ara-C (case 5). Transformation to acute myeloid leukemias (AML) occurred in three/five patients (cases 1, 2, and 4) 26, 12, and 22 months after diagnosis of CMMoL, respectively. We conclude that +19 as the sole anomaly is a rare but recurrent change in CMMoL, in particular of the proliferative type. It is at present unclear which gene(s) located on chromosome 19 might have a functional role for the development of this phenotype.

Rhabdomyolysis following laparoscopic gastric bypass.

Rhabdomyolysis is a rare complication of serious surgical procedures, and constitutes a clinical and biochemical syndrome, caused by injury and destruction of skeletal muscles. It is accompanied by pain in the region of the referred muscle group, increase in creatine phosphokinase levels, myoglobinuria, often with severe renal failure, and finally multi-organ system failure and death, if not treated in time. The main risk factor in the development of postoperative rhabdomyolysis is prolonged intraoperative immobilization of the patient. Morbidly obese patients who undergo laparoscopic bariatric operations should be considered high-risk for rhabdomyolysis, from extended immobilization and pressure phenomena in the lumbar region and gluteal muscles. We report a 20-year-old woman with BMI 51, who underwent a prolonged laparoscopic Roux-en-Y gastric bypass. Postoperatively, she presented severe myalgia in the gluteal muscles and lumbar region, oliguria and creatine phosphokinase levels that reached 38,700 U/L. She was treated with intensive hydration and analgesics, and did not develop acute renal failure because diagnosis and treatment were attained immediately.

Modifications of the learning curve guidelines for breast cancer sentinel node biopsy.

BACKGROUND: Guidelines for the learning period of sentinel lymph node biopsy in breast cancer do not address important details such as the false negative rate way of calculation and the number of patients with positive axilla that should be included among the cases of this period. The aim of this study was to identify refinement points which should be included in the guidelines. METHODS: We studied 138 breast cancer cases of the sentinel lymph node biopsy learning period of three surgeons. The sentinel node was identified using isosulfan blue or technetium sulfur colloid or both. All patients underwent complementary axillary dissection. RESULTS: All three surgeons (A, B, C) fulfilled the guidelines' false negative rate criteria of 5, 0 and 5%, respectively, after 20 cases. However, only six, 10 and 10 cases with positive axilla, respectively, were included and the false negative rates using only these cases were 17, 0 and 10%, respectively. CONCLUSIONS: Current guidelines may lead surgeons to inappropriate conclusions about their ability to perform sentinel lymph node biopsy with an acceptable false negative rate. The learning period should include as many cases with positive axilla as possible and the false negative rate should be calculated only on those patients.

Synthesis and structural and spectroscopic characterization of a complex between Co(II) and imino-bis(methylphosphonic acid): gaining insight into biologically relevant metal-ion phosphonate interactions or looking at a new Co(II)-organophosphonate material?

Cobalt is an essential metal ion involved in key biomolecules, regulating processes in human physiology. As a metal ion, Co(II) assumes forms, which are dictated by the nature of organic binders in biological fluids, and the conditions under which metal ion ligand interactions arise. Among the various low molecular mass metal ion binders in biological fluids are amino acids, organic acids, as well as their variably phosphorylated forms. As a representative metal ion binder, the organophosphonate ligand H(2)O(3)P-CH(2)-NH(2)(+)-CH(2)-PO(3)H(-) was employed in aqueous reactions with Co(II), ultimately leading to the isolation of complex [Co(C(2)H(8)O(6)NP(2))(2)(H(2)O)(2)] (1) at pH 2. The complex was characterized analytically, spectroscopically (FTIR, UV-vis, EPR), and magnetically. Compound 1 crystallizes in the monoclinic space group P2(1)/n, with a = 7.361(3) A, b = 8.133(3) A, c = 14.078(5) A, beta = 104.40(1) degrees, V = 816.3(5) A(3), and Z = 2. X-ray crystallography reveals that 1 is a compound with a molecular type of lattice. In it, there exist mononuclear octahedral sites of Co(II) surrounded by oxygens, belonging to terminal phosphonates and bound water molecules. Both ends of the ligand zwitterionic form are involved in binding to adjacent Co(II) ions, thus creating tetranuclear 32-membered rings, with cavities extending in two dimensions and holes in the third dimension throughout the lattice of 1. Similar structural features were observed in other metal organophosphonate lattices of potential catalytic and chemical reactivity. The magnetic and EPR data on 1 support the presence of a high-spin octahedral Co(II) in an oxygen environment, having a ground state with an effective spin S = (1)/(2). The solution UV-vis and EPR data suggest retention of the high-spin octahedral Co(II) ion, consistent with the magnetization measurements on 1. Collectively, the data reflect the existence of a soluble Co(II)-iminodiphosphonate species not unlike those expected in biological fluids containing the specific ligand or ligands similar to that. Both biologically relevant perspectives and a synthetic outlook into Co(II)-organophosphonate materials are discussed.

High protein intake during continuous hemodiafiltration: impact on amino acids and nitrogen balance.

AIMS: To study the effect of combined continuous veno-venous hemodiafiltration (CVVHDF) and high (2.5 g/kg/day) parenteral amino acid supplementation on nitrogen balance, amino acid losses and azotemic control in a cohort of patients with severe acute renal failure (ARF). METHODS: We administered 2.5 grams/kg/day of amino acids intravenously to seven critically ill patients with ARF. We obtained paired blood and ultrafiltrate (UF) samples (n=20) and calculated amino acid clearances and losses, nitrogen balance, protein catabolic rate and total nitrogen losses. RESULTS: The median total serum amino acid concentration was high at 5.2 mmol/L with particularly high concentrations of ornithine, lysine, and phenylalanine, but a low level of histidine. The median overall amino acid clearance was 18.6 ml/min (range: 12 to 29 ml/min). UF losses as percentage of administered dose were high for tyrosine (53.6%) but low for methionine (3.0%) and arginine (2.3%). A positive nitrogen balance was achieved in 7 (35%) of the 20 study days with an overall median nitrogen balance of -1.8 g/day. Urea levels were maintained at a median of 26.6 mmol/L. CONCLUSIONS: High protein intake increases the serum concentrations of most amino acids. Such protein supplementation, when coupled with CVVHDF achieves a slightly negative overall nitrogen balance in extremely catabolic patients while still allowing adequate azotemic control.

Variability of standard clinical protein assays in the analysis of a model urine solution of fragmented albumin.

OBJECTIVES: This study investigates the sensitivity of various standard clinical techniques in the detection of albumin fragments. The significance of this work is in the detection of urinary proteins, such as albumin, which has recently been discovered to be excreted as mainly peptide fragments as a result of filtered albumin undergoing degradation during renal passage. All filtered proteins undergo a similar degradation process. DESIGN AND METHODS: Albumin digested with trypsin was used as a model urine solution. The solution was assayed for albumin concentration by various methods including the biuret assay that is known to detect urinary albumin fragments. The digest solution was also analyzed by various clinically used chromagen assays, electrophoretic and chromatographic methods to determine whether they are able to detect the fragmented protein. RESULTS: The benzethonium chloride, Coomassie blue, and pyrogallol red assays for urine protein, the immunoassay for human albumin and sodium dodecyl sulfate polyacrylamide gel electrophoresis with Coomassie blue staining were unable to detect the albumin fragments. Capillary electrophoresis was sensitive to the fragments but with low resolution. High-performance liquid chromatography gave the best results. CONCLUSIONS: Many techniques utilized to assay patient urine samples are unable to detect fragmented albumin and, hence, will severely underestimate albumin and protein excretion.

Ciliary body PDT in pigmented rabbit eyes: effect of single and repeated treatment.

PURPOSE: To investigate the morphologic and hypotensive effect of contact transscleral ciliary body PDT in pigmented rabbit eyes. METHODS: The right eyes of 33 pigmented rabbits were irradiated using chloraluminum sulfonated phthalocyanine as photosensitizer and a diode laser (670 nm) as the light source. Twenty-five animals received a single treatment. Eight animals received a second treatment 13 days after the first one. Photosensitizer was administered by means of continuous intravenous infusion. Ciliary body was irradiated transsclerally by means of an optic fiber applied on the corneoscleral limbus. In all cases 14-16 laser applications were performed to cover 360 degrees of the ciliary body. Animals were followed for a maximum of 30 days by means of tonometry and biomicroscopy. Retreatments were performed using the same irradiation protocol. At the end of the follow up time animals were sacrificed and their were eyes prepared for light and electron microscopy. RESULTS: Transscleral ciliary body PDT resulted in significant but temporary reduction of IOP in all cases. The effect lasted about two weeks. Retreatment led to a new significant drop of the IOP, which lasted about two weeks again. In histological examination the initial effect was vascular thrombosis, followed by edema and disintegration of the ciliary epithelial layers. In all cases the appearance of the ciliary body had returned to normal 15 days after irradiation. CONCLUSION: Contact transscleral PDT with the treatment parameters used in this study results in significant but temporary functional and morphological alteration in pigmented rabbits ciliary body.

Clinical associations and characterisation of antineutrophil cytoplasmic antibodies directed against bactericidal/permeability-increasing protein and azurocidin.

Bactericidal/permeability-increasing protein (BPI) and azurocidin (AZ) are recently described target antigens of antineutrophil cytoplasmic antibodies (ANCA). In this study, BPI-ANCA were demonstrated most often in patients with ulcerative colitis (36/92, 39%), Crohn's disease (17/66, 26%) and cystic fibrosis (11/14, 79%), but also in patients with rheumatoid arthritis (8/40, 20%), systemic lupus erythematosus (SLE) (111/65, 17%) and mixed connective tissue disease (4/18, 22%). BPI-ANCA were also common in sera containing antinuclear (ANA) (9/43, 21%) or antidouble-stranded (ds) DNA (7/28, 25%) antibodies. There was no increased frequency of abnormal alpha1-antitrypsin (alphal1AT) phenotypes in patients with BPI-ANCA, and BPI-ANCA were not more common in individuals with an abnormal phenotype. The predominant IgG subclasses were IgG1 and IgG3; IgA but not IgM was present. Both IgG and IgA BPI-ANCA were high affinity antibodies, and the affinity of IgG antibodies did not change with time in the sera tested. Four of the five sera (80%) containing BPI-ANCA did not bind to denatured, reduced BPI, suggesting that most BPI-ANCA recognised conformational epitopes. AZ-ANCA were demonstrated in 2/11 patients (18%) with Wegener's granulomatosis, 3/12 (25%) with cystic fibrosis and 3/14 (21%) with chronic active hepatitis. AZ-ANCA were present in 5/25 sera (25%) with ANA, but the levels were only marginally elevated. AZ-ANCA were uncommon in patients with inflammatory bowel and rheumatological diseases, and in sera containing other autoantibodies. Again, there was no association with abnormal alpha1-AT phenotypes. BPI represents a major ANCA target antigen in patients with rheumatological as well as inflammatory bowel disease and cystic fibrosis, but AZ-ANCA are uncommon.

Cytosine demethylation of the proteinase-3/myeloblastin primary granule protease gene during phagocyte development.

Proteinase-3/Myeloblastin (Mbn) is a neutral serine protease and a major constituent of the primary granules of myeloid cells. It can degrade extracellular matrix proteins and has been discussed as a key factor for the initiation of terminal differentiation in promyelocytic cells. Regulation of Mbn closely parallels that of another major primary granule protein, myeloperoxidase (MPO). We examined the expression and DNA methylation of Mbn in a model of in vitro differentiation of CD34+ enriched peripheral blood progenitor cells (PBPCs), and in various other myeloid and non-myeloid tissues. Mbn mRNA was undetectable in uncultured PBPCs but was upregulated during their in vitro differentiation. Its expression was enhanced in the presence of G-CSF. Mbn expression was also detected in several myeloid cell lines but not in mature granulocytes, monocytes and macrophages. Partial demethylation at a CpG site within Mbn intron 1 (analyzed by restriction with SmaI) was observed during continued in vitro differentiation of PBPCs. This site was fully demethylated in mature granulocytes, monocytes and macrophages. Variable methylation of this site and a second SmaI site located upstream of the putative Mbn promoter region was present in other myeloid and non-myeloid tissues examined.