Hand-assisted laparoscopic living donor nephrectomy: initial Glasgow experience.

AIMS: The study presents the early results of hand-assisted laparoscopic living donor nephrectomy (HALDN) carried out in West of Scotland from June 2009 to October 2010. METHODS: The first 20 HALDN procedures carried out in our unit are presented. The outcomes reported are warm ischaemia time, operative time, delayed graft function, recipient renal function and one-month morbidity and mortality of donor and recipient. SPSS 15.0 was used for statistical analysis. RESULTS: The mean age of the donors was 44 ± 10 years, predominantly females (n = 13), median operative time 135 ± 33 min and warm ischaemia time 41 ± 16 s. The length of the incision used was 65 mm in all cases. Duration of hospital stay was 5 ± 1 days. Patient mortality was 0 and morbidity minimal with two donors developing minor wound infection and no other clinically significant postoperative morbidity. Among the recipients, 18/20 (90%) transplants worked primarily with two delayed graft functions, one due to early surgical complications in a small paediatric recipient and one due to recipient renal artery thrombosis. CONCLUSION: HALDN is safe and associated with minimal morbidity; further analysis aims to confirm excellent cosmetic results and quick return to activity compared with the standard open nephrectomy technique.

Pyogenic ventriculitis following enteral bacterial translocation in a patient with small bowel obstruction.

The authors present a rare case of ventriculitis secondary to cerebro spinal fluid (CSF) colonization with Escherichia coli species in a 65-year-old woman. Passage of bacterial organisms from the lumen of the gastrointestinal tract to the bloodstream or lymphatic tissue is known as translocation. Once in the bloodstream, particular bacteria are able to cross the blood-brain barrier and migrate to CSF. Elective abdominal surgery, intestinal obstruction, colorectal cancer, ischaemic reperfusion injury and pancreatitis have all increased the risk of this phenomenon. This account highlights particular events in presentation and management of such a case, followed by a brief literature review.

Meiosis: step-by-step through sporulation.

A transcription factor, Ndt80p, has been identified that has a critical role in the pathway that controls meiosis--sporulation--in budding yeast. Ndt80p coordinately controls genes that mediate spore formation and progression through the two meiotic divisions; it may also be a target of a checkpoint control.

IME4, a gene that mediates MAT and nutritional control of meiosis in Saccharomyces cerevisiae.

In the yeast Saccharomyces cerevisiae, sporulation occurs in response to nutritional and genetic signals. The process is initiated when nutrient availability limits mitotic growth, but only in MATa/MAT alpha diploid cells. Under these conditions, the cells express an activator of meiosis (IME1), which is required for the expression of early sporulation-specific genes. We describe a new gene, IME4, whose activity is essential for IME1 transcript accumulation and sporulation. The IME4 transcript was induced in starved MATa/MAT alpha diploids but not in other cell types. In addition, excess IME4 promoted sporulation in mat-insufficient cells. Thus, IME4 appears to activate IME1 in response to cell type and nutritional signals. We have also explored the interactions between IME4 and two genes that are known to regulate IME1 expression. Normally, cells that lack complete MAT information cannot sporulate; when such strains lack RME1 activity or contain the semidominant RES1-1 mutation, however, they can express IME1 and sporulate to low levels. Our results show that mat-insufficient strains containing rme1::LEU2 or RES1-1 bypass mutations still retain MAT control of IME4 expression. Even though IME4 levels remained low, the rme1::LEU2 and RES1-1 mutations allowed IME1 accumulation, implying that these mutations do not require IME4 to exert their effects. In accord with this interpretation, the RES1-1 mutation allowed IME1 accumulation in MATa/MAT alpha strains that contain ime4::LEU2 alleles. These strains still sporulated poorly, suggesting that IME4 plays a role in sporulation in addition to promoting IME1 transcript accumulation. IME4 is located between ADE5 and LYS5 on chromosome VII.

Developmental regulation of a sporulation-specific enzyme activity in Saccharomyces cerevisiae.

An alpha-glucosidase activity (SAG) occurs in a/alpha Saccharomyces cerevisiae cells beginning at about 8 to 10 h after the initiation of sporulation. This enzyme is responsible for the rapid degradation of intracellular glycogen which follows the completion of meiosis in these cells. SAG differs from similar activities present in vegetative cells and appears to be a sporulation-specific enzyme. Cells arrested at various stages in sporulation (DNA replication, recombination, meiosis I, and meiosis II) were examined for SAG activity; the results show that SAG appearance depends on DNA synthesis and some recombination events but not on the meiotic divisions.

Localization of proteins in the inner and outer membranes of Caulobacter crescentus.

Cytoplasmic and outer membranes of Caulobacter crescentus were separated by isopycnic sucrose gradient centrifugation into two peaks with buoyant densities 1.22 and 1.14 g/cm3. These peaks were identified as outer and cytoplasmic membranes by the enrichment of malate dehydrogenase and NADH oxidase in the lower density peak and the presence of flagellin, a cell surface protein, in the heavier peak. The identity of the heavier peak as outer membrane was confirmed by labeling of cells with diazotized [35S]sulfanilic acid, a reagent that does not penetrate intact cells. Under these conditions only outer membrane proteins were substituted by the sulfanilic acid. The distribution of proteins between the cytoplasmic and outer membranes were examined by the analysis of [35S]methionine-labeled membranes by SDS-polyacrylamide and two-dimensional gel electrophoresis. These results showed that the inner and outer membranes contain approximately equal numbers of proteins, and that the distribution of these proteins between the two layers is highly asymmetric. Although many of the proteins could be assigned to one or the other membrane fraction, a number of the outer membrane proteins in the 32 000-100 000 molecular weight range frequently contaminate the inner membrane fractions. The implications of these results for membrane isolation and separation in C. crescentus are discussed.

Characterization and localization of the sporulation glucoamylase of Saccharomyces cerevisiae.

Glucoamylase (SGA) was purified approximately 250-fold from sporulating Saccharomyces cerevisiae cells. The partially purified enzyme was active against glycogen, starch, maltotriose and maltose. It exhibited maximum catalytic activity against glycogen at pH 5.5. The enzyme appears to be glycosylated, because it bound to lentil-lectin Sepharose. SGA was expressed in vegetatively growing cells under the control of the GAL1 promoter, and the cellular location of the enzymatic activity determined by fractionation techniques. SGA was preferentially recovered in fractions which were enriched for the vacuolar hydrolases, carboxypeptidase Y and alpha-mannosidase.

An RME1-independent pathway for sporulation control in Saccharomyces cerevisiae acts through IME1 transcript accumulation.

The RES1-1 mutation was isolated on the basis of its ability to allow MATa/MAT alpha diploid Saccharomyces cerevisiae cells to express a late sporulation-regulated gene, SPR3, in the presence of excess copies of RME1. RME1 is a repressor of meiosis that is normally expressed in cells that lack the a1/alpha 2 repressor encoded by MAT. The RES1-1 mutation also supports sporulation in mat-insufficient diploids. This phenotype does not result from a failure to express RME1 and is not due to activation of the silent copies of mating type information. RES1-1 activates sporulation by allowing IME1 accumulation in all cell types, irrespective of the presence of the MAT products. IME1 is still responsive to RME1 in RES1-1 cells, since double mutants (rme1 RES1-1) that are deficient at MAT can sporulate better than either single mutant. RES1-1 is not an allele of IME1.

The SPR3 gene encodes a sporulation-specific homologue of the yeast CDC3/10/11/12 family of bud neck microfilaments and is regulated by ABFI.

The SPR3 gene is selectively activated only during the sporulation phase of the Saccharomyces cerevisiae (Sc) life cycle. The predicted amino acid (aa) sequence has homology to microfilament proteins that are involved in cytokinesis and other proteins of unknown function. These include the products of Sc cell division cycle (CDC) genes involved in bud formation (Cdc3p, Cdc10p, Cdc11p and Cdc12p), Candida albicans proteins that accumulate in the hyphal phase (CaCdc3p and CaCdc10p), mouse brain-specific (H5p) and lymphocyte (Diff6p) proteins, Drosophila melanogaster (Dm) protein Pnutp (which is localized to the cleavage furrow of dividing cells), a Diff6p homologue (DmDiff6p), and the Sc septin protein (Sep1hp), a homologue of the 10-nm filament proteins of Sc. One strongly conserved region contains a potential ATP-GTP-binding domain. Primer extension analysis revealed six major transcription start points (tsp) beginning at -142 relative to the ATG start codon. The sequence immediately upstream from the tsp contains consensus binding sites for the HAP2/3/4 and ABFI transcription factors, a T-rich sequence and two putative novel elements for mid to late sporulation, termed SPR3 and PAL. Electrophoretic mobility shift assay (EMSA) and footprint analyses demonstrated that the ABFI protein binds to a region containing the putative ABFI site in vitro, and site-directed mutagenesis showed that the ABFI motif is essential for expression of SPR3 at the appropriate stage in sporulating cells.

The use of ultrasound in the non-invasive detection of changes in the renal circulation in response to blood loss using an animal model.

Using a continuous haemorrhage model, 8 anaesthetised swine were bled 1 ml/kg per min for 30 min. The resistance index (RI) of the main renal artery, interlobar and arcuate vessels all significantly increased. Cortical Doppler signals were lost in 4 animals at a mean arterial pressure of 26 mmHg. After reinfusion of blood and normal saline only the RI of the interlobar vessels was significantly different from baseline readings. Ultrasound demonstrated non-invasively changes in regional blood flow within the kidney in response to hypovolaemic shock.

Volumetric flow estimation in vivo and in vitro using pulsed-Doppler ultrasound.

The measurement of volumetric blood flow in small vessels in vitro and in vivo poses a significant technological challenge. In this study, two pulsatile flow models were developed, one with a 3.2-mm lumen diameter and one with a 12.7-mm lumen diameter, to assess the accuracy of volumetric flow estimation of two pulsed-Doppler devices, a Crystal Biotech VF1 20-MHz system with either a cuff-mounted or a needle-mounted probe and an Advanced Technology Laboratories Ultramark 9 High Definition Imaging system with a 5-MHz linear array transducer. The VF1 volumetric flow error was measured in the 3.2-mm phantom over a variety of pulsatile and continuous waveforms. The accuracy of the VF1 was also tested in porcine femoral and renal arteries. VF1 volumetric flow error ranged from 4.8% to 54.3% in the in vivo studies. The ATL demonstrated similar volumetric flow errors in the porcine femoral artery (approximately 3.2 mm diameter), but these errors were reduced to < or = 17.4% in the 12.7-mm-diameter in vitro flow model.

Point of care testing in the accident and emergency department: a cost analysis and exploration of financial incentives to use the technology within the hospital.

OBJECTIVES: To compare the costs of current arrangements for testing emergency blood samples from patients attending an accident and emergency (A&E) department in a large teaching hospital in England with point of care testing (POCT). METHODS: Estimates were made of the fixed and variable costs of two options: a supplemental option, in which POCT was introduced to A&E only; and a replacement option, in which POCT was introduced to A&E and the intensive therapy unit (ITU), thereby entirely replacing an existing process. RESULTS: For the supplemental option, current arrangements cost 68,466 Pounds in total per year; average costs per test were 5.53 Pounds (venous in the central laboratory) and 3.60 Pounds (arterial on the ITU). Introducing POCT would increase total hospital costs by 35,929 Pounds, and average costs per test would be 5.32 Pounds (venous) and 4.28 Pounds (arterial). For the replacement option, current arrangements cost 132,630 Pounds in total, and average cost per test (for all tests) was 4.06 Pounds. Introducing POCT would make hospital savings ranging from 8332 Pounds to 20,000 Pounds, and average cost per test would be 3.78 Pounds. CONCLUSIONS: Introducing POCT results in lower average costs per test. The supplemental option will result in significantly increased costs to the hospital. The replacement option can lead to significant savings. The internal cross-charging arrangements between departments that exist in this hospital may mean that supplemental implementation of POCT could be potentially 'profitable' for the A&E department, but would result in higher expenditure for the hospital as a whole.

The effects of anabolic agents and breed on the fibers of the longissimus muscle of male cattle.

Sample of longissimus muscle were taken from carcasses of steers, steers implanted with anabolic agents and bulls of Friesian and Charolais X Friesian breeds of cattle. Percent and mean cross-sectional areas (CSA) of three myofiber types (beta R, alpha R and alpha W) were determined. The percentage of beta R myofibers did not vary significantly with treatment. The implanted steers had 26% more alpha R and 8% less alpha W myofibers than the untreated steers, while the bulls had 33% more alpha R and 20% less alpha W myofibers than the implanted steers (P less than .001). In the implanted steers the mean CSA of the beta R myofibers was significantly greater than that of the untreated steers, but did not differ from that of the bull. The mean CSA of the alpha R myofibers increased considerably with treatment, but only that of the bull was significantly greater than that of the untreated steers. The mean CSA of the alpha W myofibers in the implanted steers was identical with that of the untreated steers and significantly smaller than that of the bulls. In comparison to the untreated steers, significant hypertrophy of all three myofiber types occurred in bulls. These findings demonstrate a significant increase in the oxidative capacity of the longissimus when the levels of both endogenous and exogenous anabolic agents are increased. They are also consistent with the greater efficiency of deposition of protein obtained with implanted steers and bulls.(ABSTRACT TRUNCATED AT 250 WORDS)

Clearing the cervical spine of paediatric trauma patients.

OBJECTIVES: To review the evidence available for clearance of the cervical spine in children under 16 years of age after trauma, and to provide guidance to enable this to be practised safely. METHODS: A comprehensive literature review was carried out, and combined with a review of standard texts and liaison with experts. RESULTS: 241 papers were identified, of which 71 papers were thought possibly relevant. These were obtained and appraised. Children in whom there is concern about possible cervical spine injury may be divided into three groups. Alert, asymptomatic children with a normal examination may be clinically cleared without need for radiology. Children with cervical spine symptoms or signs require plain radiology in the first instance. Those areas that are poorly visualised or suspicious should be discussed with a paediatric radiologist and are likely to undergo computed tomography. Children with impaired conscious level require careful evaluation. Plain radiology, if normal, can be usefully complemented by early magnetic resonance imaging to exclude ligamentous and spinal cord damage. CONCLUSIONS: There is limited evidence to guide clinicians on how to clear the paediatric cervical spine. The approach suggested is similar to adult recommendations made elsewhere, and the differences are highlighted.

Laryngopharyngeal pH measurement.

OBJECTIVES: Most emergency department (ED) intubations are to prevent gastric contents aspiration. The incidence of aspiration is unknown and intubation has complications. Balancing these risks requires an idea of the incidence of aspiration. This study assessed one technique for investigating the aspiration risk in ED patients. Cricoid pressure is used to reduce this risk and the technique may also examine this manoeuvre. METHODS: Cohorts of unconscious adult ED and elective surgical patients were recruited. The posterior pharyngeal wall pH was measured immediately before and after intubation. Pharyngeal pH was used to indicate risk of aspiration, and pH change to assess the efficacy of cricoid pressure. RESULTS: Eight ED and 48 control patients were recruited. In the ED cohort, pH ranged from 6.0 to 8.0 before intubation and 4.7 to 8.0 after intubation: a mean decrease of 0.3 (95% CI 1.5 decrease to 0.9 increase). In the control cohort pH ranged from 5.8 to 8.0 before intubation and 6.0 to 8.0 after intubation: a mean increase of 0.4 (95% CI 0.1 to 0.6 increase). CONCLUSIONS: This is a simple, cheap, and repeatable technique for assessing aspiration risk in emergency intubations. A larger study is required to assess the efficacy of cricoid pressure.

Bronchoscopic removal of an inhaled, sharp, foreign body: an unusual complication.

A case is reported in which an inhaled sewing needle, stuck fast in the trachea, became displaced through the tracheal wall during attempted removal via flexible bronchoscopy. The inherent risks and pitfalls of this procedure are highlighted.

Answer please. Blount's disease: tibia vara.

Infantile tibia vara, although uncommon compared to normal physiologic bowing, is significant due to the resultant progressive deformities if not diagnosed early. The key radiographic finding is medial tibial metaphyseal beaking and fragmentation. Although the etiology is unclear, it appears to be an acquired growth disturbance of the proximal medial tibial epiphysis, ossification center, and metaphysis rather than any type of avascular necrosis. The Langenskiöld six-stage classification is useful for the diagnostic, prognostic, and treatment staging of the disease. The adolescent form is less common and less severe with only slight irregular thickening of the physis present on radiograph. The MDA appears to be the most reproducible method for measuring angular deformities in both variants of the disease. Treatment of the infantile stages I or II consists of observation and bracing. Stage III or IV disease in children over age 3 years with more than 5 degrees of varus angulation should be treated with corrective valgus osteotomy. Stages V or VI may require repeated surgical treatment with multiple osteotomies and possible contralateral epiphysiodesis. The adolescent form frequently requires surgery when there is significant physical impairment related to the severe genu varum.

Below-target postoperative arterial blood pressure but not central venous pressure is associated with delayed graft function.

Delayed graft function (DGF) is a major issue in kidney transplantation and is associated with reduced graft and patient survival. The condition results from the summative effects of multiple injurious processes associated with transplantation with many underlying factors being nonmodifiable. Reducing cold ischemic time and machine perfusion have decreased the DGF incidence but peri-/postoperative injury resulting from suboptimal perfusion may also be critical to the development of DGF. We investigated the effect of perfusion parameters and other key variables on the incidence of DGF in 149 consecutive renal transplants. The occurrence of any recorded subtarget (70 mm Hg) mean arterial pressure (MAP) was significantly associated with DGF (perioperative P = .005; postoperative P = .002) while the occurrence of a subtarget (8 cm H(2)O) central venous pressure (CVP) among other variables was not. Routine continuous blood pressure monitoring is rare postoperatively and is shown to be more accurate than CVP in assessing renal perfusion and guiding management in the postoperative period.