Bringing damage control surgery simulation to life: developing a novel surgical anatomy model within immersive military trauma surgery simulation.

Haemorrhage from junctional injuries remains the most common cause of battlefield death. Changes to surgical training have meant acquiring and maintaining trauma surgical skills is becoming more difficult for military surgeons. The multidisciplinary Military Operational Specialist Team Training (MOSTT) course is designed to bridge the gap between civilian practice and the deployed environment, as part of predeployment trauma training. It involves immersive team simulation and uses cadaveric dissection for surgical skills practice.A novel surgical anatomy model, featuring junctional haemorrhage surgical task trainers of the groin and shoulder, was designed using reconstructed CT and MRI images obtained from a human volunteer. The model is designed to look and feel as realistic as possible, with the added dimension of pulsatile 'blood' flow from a simulation gunshot injury.This surgical anatomy model has been trialled, as part of the MOSTT course, by 90 surgeons and perioperative practitioners, with feedback analysis used for iterative model development. Feedback demonstrated that, alongside more traditional cadaveric dissection, this surgical anatomy model adds value to current predeployment training delivered within the immersive simulation of the MOSTT course. Research by the authors about the effects of this model on surgical ability and performance is ongoing. However, there is clear potential for this model to be used in other environments, including on exercises and as part of consolidation training while deployed.

Precise orientation of a single C60 molecule on the tip of a scanning probe microscope.

We show that the precise orientation of a C(60) molecule which terminates the tip of a scanning probe microscope can be determined with atomic precision from submolecular contrast images of the fullerene cage. A comparison of experimental scanning tunneling microscopy data with images simulated using computationally inexpensive Hückel theory provides a robust method of identifying molecular rotation and tilt at the end of the probe microscope tip. Noncontact atomic force microscopy resolves the atoms of the C(60) cage closest to the surface for a range of molecular orientations at tip-sample separations where the molecule-substrate interaction potential is weakly attractive. Measurements of the C(60)-C(60) pair potential acquired using a fullerene-terminated tip are in excellent agreement with theoretical predictions based on a pairwise summation of the van der Waals interactions between C atoms in each cage, i.e., the Girifalco potential [L. Girifalco, J. Phys. Chem. 95, 5370 (1991)].

Outcome after vascular trauma in a deployed military trauma system.

BACKGROUND: Military injuries to named blood vessels are complex limb- and life-threatening wounds that pose significant difficulties in prehospital and surgical management. The aim of this study was to provide a comprehensive description of the epidemiology, treatment and outcome of vascular injury among service personnel deployed on operations in Afghanistan and Iraq. METHODS: Data from the British Joint Theatre Trauma Registry were combined with hospital records to review all cases of vascular trauma in deployed service personnel over a 5-year interval ending in January 2008. RESULTS: Of 1203 injured service personnel, 110 sustained injuries to named vessels; 66 of them died before any surgical intervention. All 25 patients who sustained an injury to a named vessel in the abdomen or thorax died; 24 did not survive to undergo surgery and one casualty in extremis underwent a thoracotomy, but died. Six of 17 patients with cervical vascular injuries survived to surgical intervention; two died after surgery. Of 76 patients with extremity vascular injuries, 37 survived to surgery with one postoperative death. Interventions on 38 limbs included 19 damage control procedures (15 primary amputations, 4 vessel ligations) and 19 definitive limb revascularization procedures (11 interposition vein grafts, 8 direct repairs), four of which failed necessitating three amputations. CONCLUSION: In operable patients with extremity injury, amputation or ligation is often required for damage control and preservation of life. Favourable limb salvage rates are achievable in casualties able to withstand revascularization. Despite marked progress in contemporary battlefield trauma care, torso vascular injury is usually not amenable to surgical intervention.

Socioeconomic deprivation adversely affects survival of patients with rectal cancer.

BACKGROUND: The aim was to examine the influence of socioeconomic deprivation on stage at presentation, perioperative mortality, permanent stoma rates and overall survival in patients with rectal cancer. METHODS: Data on patient demographics, mode and stage of presentation, and short- and longer-term outcomes were extracted from a database of patients with rectal cancer. Comparisons were made after stratification into quintiles of socioeconomic deprivation. RESULTS: In total 486 patients were identified. Fewer patients from the most deprived group than from the least deprived group underwent resectional surgery (79.2 versus 93 per cent; P = 0.005). Permanent stoma rates among patients who had surgery were 40.8 and 30 per cent respectively (P = 0.110). The overall 5-year survival rate was 32.8 per cent for the most deprived compared with 64.0 per cent for the least deprived patients (P < 0.001). Respective rates for those who underwent resectional surgery were 49.9 and 72 per cent (P = 0.030). CONCLUSION: In rectal cancer, socioeconomic deprivation appears to be associated with poorer outcomes and survival. This has important implications for healthcare planning.

Modelling approaches to the dewetting of evaporating thin films of nanoparticle suspensions.

We review recent experiments on dewetting thin films of evaporating colloidal nanoparticle suspensions (nanofluids) and discuss several theoretical approaches to describe the ongoing processes including coupled transport and phase changes. These approaches range from microscopic discrete stochastic theories to mesoscopic continuous deterministic descriptions. In particular, we describe (i) a microscopic kinetic Monte Carlo model, (ii) a dynamical density functional theory and (iii) a hydrodynamic thin film model. Models (i) and (ii) are employed to discuss the formation of polygonal networks, spinodal and branched structures resulting from the dewetting of an ultrathin 'postcursor film' that remains behind a mesoscopic dewetting front. We highlight, in particular, the presence of a transverse instability in the evaporative dewetting front, which results in highly branched fingering structures. The subtle interplay of decomposition in the film and contact line motion is discussed. Finally, we discuss a simple thin film model (iii) of the hydrodynamics on the mesoscale. We employ coupled evolution equations for the film thickness profile and mean particle concentration. The model is used to discuss the self-pinning and depinning of a contact line related to the 'coffee-stain' effect. In the course of the review we discuss the advantages and limitations of the different theories, as well as possible future developments and extensions.

Front instabilities in evaporatively dewetting nanofluids.

Various experimental settings that involve drying solutions or suspensions of nanoparticles-often called nanofluids-have recently been used to produce structured nanoparticle layers. In addition to the formation of polygonal networks and spinodal-like patterns, the occurrence of branched structures has been reported. After reviewing the experimental results we use a modified version of the Monte Carlo model first introduced by Rabani [Nature 426, 271 (2003)] to study structure formation in evaporating films of nanoparticle solutions for the case that all structuring is driven by the interplay of evaporating solvent and diffusing nanoparticles. After introducing the model and its general behavior we focus on receding dewetting fronts which are initially straight but develop a transverse fingering instability. We analyze the dependence of the characteristics of the resulting branching patterns on the driving effective chemical potential, the mobility and concentration of the nanoparticles, and the interaction strength between liquid and nanoparticles. This allows us to understand the underlying instability mechanism.

Fingering instabilities in dewetting nanofluids.

The growth of fingering patterns in dewetting nanofluids (colloidal solutions of thiol-passivated gold nanoparticles) has been followed in real time using contrast-enhanced video microscopy. The fingering instability on which we focus here arises from evaporatively driven nucleation and growth in a nanoscopically thin precursor solvent film behind the macroscopic contact line. We find that well-developed isotropic fingering structures only form for a narrow range of experimental parameters. Numerical simulations, based on a modification of the Monte Carlo approach introduced by Rabani et al. [Nature (London) 426, 271 (2003)10.1038/nature02087], reproduce the patterns we observe experimentally.

Inhibition of atherosclerosis in apolipoprotein-E-deficient mice following muscle transduction with adeno-associated virus vectors encoding human apolipoprotein-E.

Apolipoprotein E (apoE) is a multifunctional plasma glycoprotein involved in lipoprotein metabolism and a range of cell signalling phenomena. ApoE-deficient (apoE(-/-)) mice exhibit severe hypercholesterolaemia and are an excellent model of human atherosclerosis. ApoE somatic gene transfer and bone marrow transplantation in apoE(-/-) mice results in reversal of hypercholesterolaemia, inhibition of atherogenesis and regression of atherosclerotic plaque density. Replication defective adeno-associated virus vectors (rAAVs) are an attractive system currently in clinical trial for muscle-based heterologous gene therapy to express secreted recombinant plasma proteins. Here we have applied rAAV transduction of skeletal muscle to express wild-type (epsilon3) and a defective receptor-binding mutant (epsilon2) human apoE transgene in apoE(-/-) mice. In treated animals, apoE mRNA was present in transduced muscles and, although plasma levels of recombinant apoE fell below the detection levels of our ELISA (ie <10 ng/ml), circulating antibodies to human apoE and rAAV were induced. Up to 3 months after a single administration of rAAV/apoE3, a significant reduction in atherosclerotic plaque density in aortas of treated animals was observed (approximately 30%), indicating that low-level rAAV-mediated apoE3 expression from skeletal muscle can retard atherosclerotic progression in this well-defined genetic model.

Cell-derived apolipoprotein E (ApoE) particles inhibit vascular cell adhesion molecule-1 (VCAM-1) expression in human endothelial cells.

Sub-endothelial infiltration of monocytes occurs early in atherogenesis and is facilitated by cell adhesion molecules that are up-regulated on activated endothelium. Apolipoprotein E (apoE) helps protect against atherosclerosis, in part, because apoE particles secreted by macrophages have local beneficial effects at lesion sites. Here, we hypothesize that such protection includes anti-inflammatory actions and investigate whether cell-derived apoE can inhibit tumor necrosis factor-alpha-mediated up-regulation of vascular cell adhesion molecule-1 (VCAM-1) in human umbilical vein endothelial cells (HUVECs). Two models were used to mimic endothelial exposure to macrophage-derived apoE. In the first, HUVECs were transiently transfected to secrete apoE; VCAM-1 induction inversely correlated with secretion of apoE into the media (r = -0.76, p < 0.001). In the second, incubation of HUVECs with media from recombinant Chinese hamster ovary (CHO) cells expressing apoE (CHO(apoE)) also reduced VCAM-1 in a dose-dependent manner (r = -0.70, p < 0.001). Characterization of CHO(apoE) cell-derived apoE revealed several similarities to apoE particles secreted by human blood monocyte-derived macrophages. The suppression of endothelial activation by apoE most likely occurs via stimulation of endothelial nitric oxide synthase; apoE increased levels of intracellular nitric oxide and its surrogate marker, cyclic guanosine monophosphate, while the nitric oxide synthase inhibitor, ethyl-isothiourea, blocked its effect. We propose that apoE secreted locally at lesion sites by macrophages may be anti-inflammatory by stimulating endothelium to release NO and suppress VCAM-1 expression.

Localization of apolipoprotein E receptor 2 to caveolae in the plasma membrane.

The LDL receptor (LDL-R) promotes the specific endocytosis and lysosomal delivery of extracellular lipoprotein ligands via clathrin-coated pits. It was widely assumed that other closely related members of the LDL-R gene family would have similar functions, but recent experimental evidence has revealed that one such protein, apolipoprotein E receptor 2 (apoER2), has a critical role as an "outside-in" signal transducer in the brain. ApoER2 signaling appears to require interaction between its cytoplasmic domain and adapter molecules such as Dab1, JIP 1 and JIP 2, and PSD-95. Many of the receptors for other signaling pathways affected by such adapter molecules are compartmentalized into specialized microdomains within the plasma membrane termed caveolae. Here, we show that apoER2, but not LDL-R, is localized to caveolae, supporting the concept that its physiological role is in cell signaling, rather than in endocytosing ligands.

Inability of plasma high-density lipoproteins to inhibit cell adhesion molecule expression in human coronary artery endothelial cells.

High-density lipoproteins (HDL) have several antiatherogenic actions, including the ability to sequester cellular cholesterol, to protect low-density lipoproteins from oxidation and to inhibit platelet aggregation. An early event in atherogenesis is the adhesion and recruitment of blood monocytes, a process mediated by cell adhesion molecules (CAMs), including vascular cell adhesion molecule-1 (VCAM-1) which is rapidly synthesized by endothelial cells in response to cytokines. It has been reported that HDL limits CAM expression in cultured human umbilical vein endothelial cells (HUVECs), implying that HDL also protects at an early stage in lesion development. Here, we have studied HDL suppression of CAM induction in human coronary artery endothelial cells (HCAECs), a model directly relevant to blood vessels susceptible to atherosclerosis. Arterial endothelial cells were preincubated with increasing amounts of total HDL, or different subfractions, and then activated with the inflammatory cytokine, tumor necrosis factor-alpha (TNF-alpha). Flow cytometric analysis failed to detect any downregulation of VCAM-1 or E-selectin expression by HDL in this model of vascular endothelium. Moreover, we were unable to confirm that HDL could suppress CAM induction in well-characterized, low-passage HUVECs, even though positive controls, 17beta-estradiol or a nitric oxide donor, did cause downregulation and factors such as variability in donors and HDL preparation, or culture conditions, were excluded. We tentatively conclude that, as isolated HDL did not downregulate CAM expression in cultured HCAECs or HUVECs, attenuation of CAM induction in arterial endothelium is unlikely to contribute to HDL antiatherogenic actions in vivo.

Injection site eosinophilic granulomas and collagenolysis in 3 horses.

Three horses were presented with a history of having developed raised cutaneous nodules, within 24-48 hours, in areas of previous injections using standard silicone-coated hypodermic needles. Skin biopsies were taken from a selected cutaneous nodule from all horses for histopathologic evaluation. Histologically, the nodules were consistent with a diagnosis of equine eosinophilic granuloma. A hypersensitivity reaction to the silicone, or another component of the coating formulation, was hypothesized to be responsible for these lesions. Two horses were experimentally injected using both coated and noncoated stainless steel hypodermic needles and skin biopsies were obtained 14 days after injection. The sites of the coated needle injections were characterized by severe eosinophilic granulomatous inflammation with and without collagenolysis. The eosinophilic granulomas with and without collagenolysis observed in these horses are proposed to represent a complex immunologic response to the silicone-based coating of most hypodermic needles.

Identification and characterization of LRP8 (apoER2) in human blood platelets.

Recently, we reported that apoE inhibits platelet reactivity by stimulating NO release and postulated apoE-receptor activation of intracellular NO synthase (eNOS). Here, we implicate a low density lipoprotein receptor (LDL-R) family member by studying ligand requirements using purified apoE isoforms, synthetic peptides, and the receptor antagonist, receptor-associated protein (RAP). Then, using a homology cloning approach and degenerate PCR primers to amplify the conserved Cys-rich binding domain of the LDL-R family, this receptor was identified as LRP8 (formerly termed, apoER2), a newly described brain protein with several splice variants. Immunoprecipitation of platelet membranes with anti-peptide antisera confirmed protein expression, while analysis of RNA from platelets and two megakaryocytic cell lines (Meg-01 and HEL) disclosed that the major LRP8 transcript lacked binding repeats 4-6 (LRP8delta4-6) but contained the full-length cytoplasmic tail. Sequence analysis of cytoplasmic LRP8 revealed several peptide motifs with potential for cellular signaling and we propose this as a rational mechanism through which apoE inhibits platelet aggregation.

Haemophilus paraphrophilus; a rare cause of intracranial abscess.

We report a case of a 42-year-old man man who presented with neurological symptoms and was found to have an intracranial abscess. A stereotactic aspiration of the abscess yielded a pure growth of Haemophilus paraphrophilus. The patient responded to treatment with cefotaxime. We postulate the mechanism of infection in this patient.

Apolipoprotein E and regulation of cytokine-induced cell adhesion molecule expression in endothelial cells.

Atherosclerotic plaques develop in the arterial wall from complex multicellular processes following the early recruitment of circulating monocytes. Infiltration of monocytes is mediated by cell adhesion molecules (CAMs), including vascular cell adhesion molecule-1 (VCAM-1) which is rapidly induced in endothelial cells in response to cytokines. Apolipoprotein E (apo E), a 34-kDa polypeptide, helps protect against atherosclerosis, in part, because apo E phospholipid particles secreted by macrophages may have local protective effects within lesions. Here we have investigated whether purified plasma apo E, complexed with dimyristoyl phosphatidylcholine (DMPC) vesicles, can inhibit cytokine-induced vascular cell adhesion molecule-1 (VCAM-1) expression in human umbilical vein endothelial cells (HUVECs). Expression of VCAM-1 in endothelial cells after exposure to tumour necrosis factor-alpha (TNF-alpha) or interleukin 1beta (IL-1beta) was quantified by ELISA and shown to be partially inhibited by 17beta-estradiol (40-60% inhibition) or by S-nitroso-L-glutathione, a nitric oxide donor (20-25%). However, preincubations with physiological concentrations (10-100 microg protein/ml) of apo E DMPC did not downregulate VCAM-1 expression, even with extended preincubation times. These findings were confirmed using a fluorescence-activated cell sorter (FACS) for analysis which indicated additionally that apo E-DMPC had no effect on sub-populations within the HUVEC cultures. Finally, apo E-DMPC vesicles were also unable to suppress TNF-alpha-induced upregulation of E-selectin or intercellular adhesion molecule-1 (ICAM-1). We conclude that plasma apo E is unlikely to be important in limiting endothelial activation.

Primary photosensitization related to ingestion of alfalfa silage by cattle.

A herd of 650 Holstein cows was examined for skin disease. Approximately 400 of the lactating adults were affected, but heifers, calves, and nonlactating cows were clinically normal. The condition was characteristic of primary photosensitization. Milk production of the affected cows was normal. Affected cows did not appear to be ill, and none of the cows was icteric. Three of 7 cows had high serum gamma-glutamyltransferase activities, but in the other 4 cows, activity was within the reference range. Serum activities of other hepatic enzymes were within reference ranges in the 7 cows that were examined. Hepatic biopsy specimens from 3 cows were normal. Specimens from 4 other cows had changes that ranged from minimal to mild, chronic, lymphoplasmacytic periportal hepatitis to acute, random, necrotizing hepatitis. Development of photosensitivity was related to ingestion of alfalfa silage. Acetone extracts of the alfalfa silage, but not of other feedstuffs, were found to inhibit growth of Candida albicans under ultraviolet light. Cows experimentally fed a diet composed exclusively of the alfalfa silage developed skin lesions after 6 days, but did not have detectable serum concentrations of phylloerythrin.