Use of a non-ICU specialty ward for immediate post-operative management of head and neck free flaps; a randomized controlled trial.

OBJECTIVES: Compare length of stay, flap failure rate, medical and surgical complications and cost when patients undergoing head and neck free flap reconstruction are monitored in an intensive care unit (ICU) versus a specialty ward unit postoperatively. MATERIALS AND METHODS: A prospective, non-inferiority, randomized controlled trial was conducted from 7/22/2016 to 9/12/2018 at a single institution. Patients were randomized to the ICU or specialty ward unit. Flap check protocols were identical between the groups. Perioperative and postoperative outcome variables were assessed and compared. RESULTS: 131 patients were enrolled in the study and 118 ultimately underwent head and neck free flap reconstruction. 57 were randomized to the ICU and 61 to the specialty ward unit. There were no significant differences between the ICU and specialty ward unit groups with regard to demographic variables including age, gender, co-morbidities, tobacco or alcohol use, prior chemotherapy or radiation therapy treatment. There were no significant differences in perioperative variables including need for transfusion, tracheostomy, ischemia time, blood loss, fluid administration or post-operative antibiotic use. There was no significant difference in the primary outcome variable, length of stay. There were no significant differences in the number of the medical or surgical complications, flap failure rate, or hospital costs. CONCLUSION: In this prospective, randomized controlled trial, head and neck free-flap patients cared for on a specialty ward in the immediate post-operative period had equivalent outcomes to those cared for in the ICU.

Neuroendocrine tumour at the carina of a dog.

A 10-year-old, neutered female, crossbred pit bull terrier was presented for cough, haemoptysis and rapidly progressive respiratory difficulty. Thoracic radiographs suggested a soft tissue density at the carina and bronchoscopy revealed a large, broad-based mass obstructing the entire left mainstem bronchus and half of the entrance to the right mainstem bronchus. Microscopically, the mass consisted of neoplastic cells that were packeted into small nests and had strong granular cytoplasmic immunoreactivity to synaptophysin and chromogranin A. Cytoplasmic neurosecretory granules stained strongly by the Grimelius method. A diagnosis of obstructive neuroendocrine tumour was made.

The effect of ketamine/xylazine and carbon dioxide on plasma luteinizing hormone releasing hormone and testosterone concentrations in the male Norway rat.

The effect of a commonly used anaesthetic, ketamine/xylazine and/or carbon dioxide (CO(2)) on plasma luteinizing hormone releasing hormone (LHRH) and testosterone concentrations was determined in male Sprague-Dawley rats. These values were compared with values obtained from pre-anaesthetic control samples. Ketamine/xylazine treatment did not significantly affect testosterone concentrations. In contrast, LHRH started to decrease one hour after ketamine/xylazine administration and continued to significantly decrease after 24 h. In addition, in the CO(2) euthanasia-only group, LHRH concentrations were also significantly decreased. These results suggest that ketamine/xylazine anaesthesia followed by CO(2) euthanasia 24 h later is exerting a significant effect on LHRH concentrations 24 h after anaesthetizing, while only having a slight effect on testosterone, and that CO(2) is exerting an immediate significant effect on LHRH. In conclusion, LHRH analysis should be avoided after ketamine/xylazine anaesthesia and CO(2) euthanasia.

Hemolitic action of Naja naja atra cardiotoxin on erythrocytes from different animals

A comparative study on the sensitivity of erythrocytes from different vertebrate species (avian, mammalian and reptilian) to the hemolytic action caused by cardiotoxin isolated from Naja naja atra venom was carried out. Cardiotoxin was able to induce direct hemolysis in washed erythrocytes from several animals, except for llama. The EC50 values from hemolysis of the most sensitive (cat) and the most resistant (snake) animal varied approximately tenfold. According to the cell behavior, it was possible to characterize four types of behavior: The first was observed in cat, horse and human cells; the second in rat, rabbit and dog erythrocytes; and the third only in llama erythrocytes, which were resistant to cardiotoxin concentrations up to 300 æg/ml. Finally, avian and reptilian erythrocytes were more resistant to cardiotoxin III-induced hemolysis than those of the mammalian species.

Hemolitic action of Naja naja atra cardiotoxin on erythrocytes from different animals

A comparative study on the sensitivity of erythrocytes from different vertebrate species (avian, mammalian and reptilian) to the hemolytic action caused by cardiotoxin isolated from Naja naja atra venom was carried out. Cardiotoxin was able to induce direct hemolysis in washed erythrocytes from several animals, except for llama. The EC50 values from hemolysis of the most sensitive (cat) and the most resistant (snake) animal varied approximately tenfold. According to the cell behavior, it was possible to characterize four types of behavior: The first was observed in cat, horse and human cells; the second in rat, rabbit and dog erythrocytes; and the third only in llama erythrocytes, which were resistant to cardiotoxin concentrations up to 300 µg/ml. Finally, avian and reptilian erythrocytes were more resistant to cardiotoxin III-induced hemolysis than those of the mammalian species.

Rapid subgroup identification of the flaviviruses using degenerate primer E-gene RT-PCR and site specific restriction enzyme analysis.

A simplified and rapid method for the diagnosis of all flaviviruses could provide an important tool for understanding their epidemiology. A protocol based on the use of degenerate nested oligonucleotide primers and RT-PCR was developed for the identification of flaviviruses. The primers were selected to flank the three E-gene markers that identify the viruses, giving DNA products of 971-986 (outer primers) and 859-884 bp (inner primers). Eighty five percent of E genes from flaviviruses representing most of the genus were specifically amplified, representing viruses from each of the 14 virus groups defined by the seventh International Committee for the Taxonomy of Viruses. Categorisation of the flavivirus cDNA products into the corresponding virus groups was undertaken through restriction enzyme analysis by defining conserved restriction sites common to related viruses in appropriate virus groups. Ninety percent of the known vector-borne flaviviruses with published full length E-gene sequences could be identified within 10 h.

Dengue virus type 2 in Cuba, 1997: conservation of E gene sequence in isolates obtained at different times during the epidemic.

It was recently reported that disease severity increased during the 1997 Cuban dengue 2 virus epidemic and it was suggested that this might be explained by the appearance of neutralization resistant escape mutants. We investigated these observations and ideas by sequencing 20 dengue 2 virus isolates obtained during the early (low case fatality rate) and the late (high case fatality rate) phases of the outbreak. Our results showed total conservation of the E gene sequence for these isolates suggesting that the selection of envelope gene escape mutants was not the determinant of increased disease severity. Alignment of these sequences with those available in GenBank, followed by Maximum likelihood phylogenetic analysis generated a tree, which indicated that our isolates are closely related to the virus that circulated in Venezuela in 1997/98 and subsequently in Martinique in 1998. This "American/Asian" genotype has therefore gradually dispersed across the Caribbean region during the past 5 years.

Characterization of a siberian virus isolated from a patient with progressive chronic tick-borne encephalitis.

A strain of Tick-borne encephalitis virus designated Zausaev (Za) was isolated in Siberia from a patient who died of a progressive (2-year) form of tick-borne encephalitis 10 years after being bitten by a tick. The complete genomic sequence of this virus was determined, and an attempt was made to correlate the sequence with the biological characteristics of the virus. Phylogenetic analysis demonstrated that this virus belongs to the Siberian subtype of Tick-borne encephalitis virus. Comparison of Za virus with two related viruses, a Far Eastern isolate, Sofjin, and a Siberian isolate, Vasilchenko, revealed differences among the three viruses in pathogenicity for Syrian hamsters, cytopathogenicity for PS cells, plaque morphology, and the electrophoretic profiles of virus-specific nonstructural proteins. Comparative amino acid alignments revealed 10 individual amino acid substitutions in the Za virus polyprotein sequence that were different from those of other tick-borne flaviviruses. Notably, the dimeric form of the Za virus NS1 protein migrated in polyacrylamide gels as a heterogeneous group of molecules with a significantly higher electrophoretic mobility than those of the Sofjin and Vasilchenko viruses. Two amino acid substitutions, T(277)-->V and E(279)-->G, within the NS1 dimerization domain are probably responsible for the altered oligomerization of Za virus NS1. These studies suggest that the patient from whom Za virus was isolated died due to increased pathogenicity of the latent virus following spontaneous mutagenesis.

Genome sequence analysis of Tamana bat virus and its relationship with the genus Flavivirus.

Tamana bat virus (TABV, isolated from the bat Pteronotus parnellii) is currently classified as a tentative species in the genus FLAVIVIRUS: We report here the determination and analysis of its complete coding sequence. Low but significant similarity scores between TABV and member-viruses of the genus Flavivirus were identified in the amino acid sequences of the structural, NS3 and NS5 genes. A series of cysteines located in the envelope protein and the most important enzymatic domains of the virus helicase/NTPase, methyltransferase and RNA-dependent RNA polymerase were found to be highly conserved. In the serine-protease domain, the catalytic sites were conserved, but variations in sequence were found in the putative substrate-binding sites, implying possible differences in the protease specificity. In accordance with this finding, the putative cleavage sites of the TABV polyprotein by the virus protease are substantially different from those of flaviviruses. The phylogenetic position of TABV could not be determined precisely, probably due to the extremely significant genetic divergence from other member-viruses of the family FLAVIVIRIDAE: However, analysis based on both genetic distances and maximum-likelihood confirmed that TABV is more closely related to the flaviviruses than to the other genera. These findings have implications for the evolutionary history and taxonomic classification of the family as a whole: (i) the possibility that flaviviruses were derived from viruses infecting mammals rather than from mosquito viruses cannot be excluded; (ii) using the current criteria for the definition of genera in the family Flaviviridae, TABV should be assigned to a new genus.

Extraocular muscle metastasis 16 years following primary prostate carcinoma.

An 83-year-old man with a history of localized prostate carcinoma treated 16 years prior with transurethral partial prostatectomy and radioactive seed implants presented with a 2-month history of right globe proptosis. Computed tomography demonstrated a right medial rectus mass. Serum prostate specific antigen (PSA) level was normal. Tumor biopsy revealed poorly differentiated carcinoma with diffuse staining of tumor cells with PSA and prostatic acid phosphatase. This case demonstrates that prostate carcinoma may metastasize to an extraocular muscle many years after treatment of the primary tumor and may not be accompanied by elevated serum PSA. Immunohistochemical stains are helpful in establishing the diagnosis.

Molecular epidemiology of dengue type 2 virus in Venezuela: evidence for in situ virus evolution and recombination.

Epidemic outbreaks of dengue fever (DF) were first recorded in Venezuela in 1978 and were followed by the emergence of dengue haemorrhagic fever (DHF) outbreaks in 1989. To gain a better understanding of the nature of these epidemics, the complete envelope (E) gene sequence of 34 Venezuelan dengue type 2 (DEN-2) viruses, isolated between 1997 and 2000 was determined. Of these isolates, 16 were from patients with DF and 17 were from patients diagnosed with DHF. There were no diagnostic sequence differences between them, suggesting that the E gene alone does not determine disease severity. These sequence data were also used in phylogenetic comparisons with a global sample of DEN-2 viruses, including strains collected previously from Venezuela. This analysis revealed that the ancestors of the Venezuelan viruses were Asian in origin, implying that a DEN-2 virus strain from this region was introduced into Venezuela and the wider Caribbean region during the late 1970s or the early 1980s. The phylogenetic trees further indicate that evolution of DEN-2 virus in Venezuela has occurred in situ, with differentiation into a number of distinct but co-circulating lineages, rather than the repeated introduction of new strains from other localities. By incorporating additional sequence data from the virus capsid, premembrane and membrane genes, evidence is provided that a single Venezuelan strain sequenced previously, designated Mara4, is a recombinant virus, incorporating genome sequence from Venezuelan and Asian parental viruses.

Complete coding sequence of the Alkhurma virus, a tick-borne flavivirus causing severe hemorrhagic fever in humans in Saudi Arabia.

To date, tick-borne flaviviruses responsible for hemorrhagic fever in humans have been isolated in Siberia (Omsk hemorrhagic fever virus), India (Kyasanur Forest disease virus, KFDV), and in Saudi Arabia (Alkhurma virus, ALKV). Prior to this study, only partial coding sequences of these severe pathogens had been determined. We report here the complete coding sequence of ALK virus, which was determined to be 10,248 nucleotides (nt) long, and to encode a single 3,416 amino acid polyprotein. Independent analyses of the complete polyprotein and the envelope protein provided genetic and phylogenetic evidence that ALKV belongs to the tick-borne flavivirus group, within which it is most closely related to KFDV. Analysis of structural genes, genetic distances, and evolutionary relationship indicate that ALKV and KFDV derived from a common phylogenetic ancestor and constitute two genetic subtypes of the same virus species according to current genetic criteria of classification.

Atypical ductal hyperplasia in breast core needle biopsies. Correlation of size of the lesion, complete removal of the lesion, and the incidence of carcinoma in follow-up biopsies.

We reviewed the results of all breast core needle biopsies with a diagnosis of atypical ductal hyperplasia (ADH) or atypia not otherwise specified and subsequent excisional biopsies for a 50-month period and correlated the results. Of 3,026 biopsies, 216 were diagnosed as ADH or atypia not otherwise specified, and subsequent resection was available for 105. After review, 95 qualified as ADH. Subsequent resection showed ductal carcinoma in situ (DCIS) in 13 excisions, ADH in 31, lobular carcinoma in situ in 6, and benign proliferative lesions in the remaining 45. In none of the 8 biopsies in which DCIS was found and radiographs were available for review was the radiographic lesion entirely removed. For comparison, the incidence of carcinoma in resections done for a diagnosis of DCIS, low or intermediate grade (solid, cribriform, or micropapillary type), on core needle biopsy was significantly greater (8 of 10 cases). However, the size of the lesions diagnosed as carcinoma also was significantly greater than that of the lesions diagnosed as ADH, and in none of the 8 biopsies with DCIS at excision was the lesion entirely removed at the time of biopsy. The incidence of carcinoma in excisional biopsies done for a diagnosis of ADH in core needle biopsies in our institution is relatively low, while the incidence of ADH is relatively high. Possible reasons for this include total removal of small lesions at the time of biopsy and use of the diagnostic term ADH for lesions that are not associated with coexistent DCIS.

The degree of attenuation of tick-borne encephalitis virus depends on the cumulative effects of point mutations.

An infectious clone (pGGVs) of the tick-borne encephalitis complex virus Vasilchenko (Vs) was constructed previously. Virus recovered from pGGVs produced slightly smaller plaques than the Vs parental virus. Sequence analysis demonstrated five nucleotide differences between the original Vs virus and pGGVs; four of these mutations resulted in amino acid substitutions, while the fifth mutation was located in the 3' untranslated region (3'UTR). Two mutations were located in conserved regions and three mutations were located in variable regions of the virus genome. Reverse substitutions from the conserved regions of the genome, R(496)-->H in the envelope (E) gene and C(10884)-->T in the 3'UTR, were introduced both separately and together into the infectious clone and their biological effect on virus phenotype was evaluated. The engineered viruses with R(496) in the E protein produced plaques of smaller size than viruses with H(496) at this position. This mutation also affected the growth and neuroinvasiveness of the virus. In contrast, the consequence of a T(10884)-->C substitution within the 3'UTR was noticeable only in cytotoxicity and neuroinvasiveness tests. However, all virus mutants engineered by modification of the infectious clone, including one with two wild-type mutations, H(496) and T(10884), showed reduced neuroinvasiveness in comparison with the Vs parental virus. Therefore, although the H(496)-->R and T(10884)-->C substitutions clearly reduce virus virulence, the other mutations within the variable regions of the capsid (I(45)-->F) and the NS5 (T(2688)-->A and M(3385)-->I) genes also contribute to the process of attenuation. In terms of developing flavivirus vaccines, the impact of accumulating apparently minor mutations should be assessed in detail.

Diagnostic immunoassays for tick-borne encephalitis virus based on recombinant baculovirus protein expression.

The baculovirus expression system that utilizes Autographa californica nuclear polyhedrosis virus was used to express the highly antigenic envelope protein E of a tick-borne encephalitis (TBE) complex virus, as well as a C-terminally truncated form of protein E (Etr). The recombinant proteins were produced with a histidine-tag at their carboxy-terminus. Protein purification by nickel agarose chromatography resulted in high concentrations of pure Etr protein, but only poor yields of E protein. Therefore, Etr was used to develop a sensitive and specific enzyme-linked immunosorbent assay (ELISA), as well as an immunoblot assay to detect TBE virus-specific antibodies in sera from immunized human blood donors. Sera from non-vaccinated blood donors were used as controls. The data show that the recombinant TBE virus-specific Etr protein exhibits the antigenic epitopes and conformation necessary for specific antigen-antibody recognition. Thus, the baculovirus expression system provides a cheap and easy method to generate recombinant viral antigens for TBE virus-specific serodiagnosis.

Blood biochemical profile of the South American rattlesnake (Crotalus durissus terrificus) in captivity

Blood samples were collected from 180 healthy specimens of the South American rattesnake, Crotalus durissus terrificus, in captivity. All animals were in good clinical condition. Normal biochemical reference values were established for the following: total proteins, albumin, globulins, uric acid, creatinine, urea, glucose, triglycerides, cholesterol, total lipids, calcium, phosphorus, potassium, sodium, chloride, magnesium, GOT (AST), GPT (ALT), and alkaline phosphatase (ALP). Samples were obtained by venipuncture of the ventral tail vein. Values were compared with published data for Boidae, Elapidae, and Viperidae.

Regulation of hippocampal neurogenesis in adulthood.

A substantial number of new granule neurons are produced in the dentate gyrus in adulthood in a variety of mammalian species, including humans. Numerous studies have demonstrated that the production and survival of new hippocampal neurons can be enhanced or diminished by hormones and experience. Steroid hormones of the ovaries and adrenal glands have been shown to modulate the production of immature neurons by affecting the proliferation of granule cell precursors. Aversive experiences have been demonstrated to decrease the production of immature granule cells, whereas enriching experiences, including learning, have been shown to enhance the survival of new hippocampal cells. These studies indicate that adult-generated neurons represent a unique form of structural plasticity that can be regulated by the environment, and furthermore suggest that new neurons play an important role in hippocampal function.

The Swedish mental health system. Past, present, and future.

In sum, the evolution, strengths, and weaknesses of the Swedish mental health system are quite similar to mental health systems in other Western countries; early reliance on stand-alone, state psychiatric hospitals, followed by deinstitutionalization and development of largely ambulatory, community mental health care. This evolution has been complicated in Sweden by the multiple levels and system components, the state, the county councils and the municipalities. Unlike the United States, but similar to Britain, community mental health care in Sweden is provided by two systems; treatment (and forensic services) by the county councils' mental health providers, and generic services by the municipalities' social welfare system. The resulting division of roles and responsibilities creates a strong need for collaboration and coordination of activities on behalf of consumers. It can also have the unintended disincentives to serving more difficult consumers. All these difficulties not withstanding, the Swedish mental health system has made major stride in providing quality, appropriate care.

Some toxic and enzymatic activities of Bothrops ammodytoides (yarará ñata) venom.

Bothrops ammodytoides, the smallest representative of this genus, is found only in Argentina. Venom was extracted from thirty adult specimens (35-70 cm in length, 90-300 g in weight) captured in the Province of Buenos Aires and kept in captivity. Venom yield was 3-30 mg. SDS-PAGE showed strong bands at 14.0; 23-25; 45; 54 and 63 kDa and weak bands at 17.0; 30.0; 40.0 and 85.0 kDa. Toxic activities were: LD50 (intravenous, mice) 0.5+/-0.2 microg/g; minimal procoagulant dose on human plasma (MPD-P) 35+/-2 mg/l; and minimal defibrinogenating dose (MDD, mice) 6-12 microg. Hemorrhagic and/or necrotic activities appear to play a major role in lethality; minimal hemorrhagic dose (MHD, mice) is 10+/-2 microg/g and minimal necrotizing dose (MND, mice) is 38+/-5 microg. The LD50, MPD-P and MND are among the lowest in venoms from Bothrops species found in Argentina. B. ammodytoides venom exhibited high proteolytic and phospholipase A2 activities. Most of the B. ammodytoides venom components cross-react with Bivalent Bothropic antivenom (Instituto Nacional de Producción de Biológicos ANLIS Dr. G. Malbrin, against B. alternatus and B. neuwiedii venoms). One ml of antivenom neutralizes 1.2 mg of B. ammodytoides venom.