Effect of rectus sheath block vs. spinal anaesthesia on time-to-readiness for hospital discharge after trans-peritoneal hand-assisted laparoscopic live donor nephrectomy: A randomised trial.

BACKGROUND: The role of spinal anaesthesia in patients having a transperitoneal hand-assisted laparoscopic donor nephrectomy in an enhanced recovery setting has never been investigated. OBJECTIVE: We explored whether substituting a rectus sheath block (RSB) with spinal anaesthesia, as an adjunct to a general anaesthetic technique, influenced time-to-readiness for discharge in patients undergoing hand-assisted laparoscopic donor nephrectomy. DESIGN: Prospective randomised open blinded end-point (PROBE) study with two parallel groups. SETTING: Tertiary University Hospital. PATIENTS: Ninety-seven patients undergoing a trans-peritoneal hand-assisted laparoscopic donor nephrectomy. INTERVENTION: Patients (n=52) were randomly assigned to receive a general anaesthetic and a surgical RSB with 2 mg kg-1 of levobupivacaine at the time of surgical closure or a spinal anaesthetic with hyperbaric bupivacaine 12.5 mg and diamorphine 0.5 mg (n=45) before general anaesthesia. PRIMARY OUTCOME: The primary outcome was the time-to-readiness for discharge following surgery. RESULTS: Median [IQR] times-to-readiness for discharge were 75 [56 to 83] and 79 [67 to 101] h for RSB and spinal anaesthesia and there was no significant difference in times-to-readiness for discharge (median difference 4 (95% CI, 0 to 20h; P  = 0.07)). There were no significant differences in pain scores at rest (P  = 0.91) or on movement (P = 0.66). Median 24-h oxycodone consumptions were similar (P  = 0.80). Nausea and vomiting scores were similar (P = 0.57) and urinary retention occurred in one vs. four patients with RSB and spinal anaesthesia, respectively (P  = 0.077). CONCLUSION: Substitution of RSB with spinal anaesthesia using 12.5 mg hyperbaric bupivacaine and 0.5 mg diamorphine, together with a general anaesthetic failed to confer any benefit on time-to-discharge readiness following transperitoneal hand-assisted laparoscopic donor nephrectomy. RSB provided similar analgesia in the immediate postoperative period with a low frequency of side-effects in this cohort. TRIAL REGISTRATION: ClinicalTrial.gov identifier: NCT02700217.

Laparoscopic hand-assisted adrenalectomy for tumours larger than 5 cm.

OBJECTIVE: Adrenal surgery remains a distinct surgical challenge. Technical challenges associated with laparoscopic adrenalectomy are tumour size, haemorrhage control and oncological compromise. Hand-assisted laparoscopic (HAL) adrenalectomy, utilizing a hand-port device, offers minimally invasive surgery with the advantages and safety of tactile feedback. We aimed to assess the efficacy of HAL for patients requiring adrenalectomy for tumours over 5 cm in size. CONTEXT: Hand-assisted laparoscopic surgery is used in several surgical specialities over totally laparoscopic surgery to manage sizeable pathology, reduce operating time and conversion rates. HAL adrenalectomy is demonstrated in this series as a safe alternative to laparoscopic adrenalectomy for large adrenal tumours. DESIGN: A retrospective analysis of all HAL adrenalectomies performed over 8 years (October 2006-May 2015) by a single surgeon was performed. This case series is the largest study of this technique. PATIENTS: All patients who were fit for surgery with adrenal tumours (over 5 cm) were included. ANALYSIS: Primary endpoints were overall mortality, operating time, hospital stay, complications and conversion to open surgery. RESULTS: A total of 56 patients underwent the procedure. A total of 43 had unilateral and 13 bilateral lesions. Most lesions (45) were histologically benign. These included functioning and non-functioning tumours. Median tumour size was 8 cm (range 5-19 cm). There was one (1.8%) intra-operative conversion and no peri-operative mortality. Postoperative complications occurred in 8 (14%) patients, all self-limiting. The median length of stay was 6 days (range 2-21). There was one recurrence of pathology with repeat surgery. CONCLUSION: Hand-assisted laparoscopic surgery offers a safe reproducible approach to adrenal surgery combining minimally invasive surgery with tactile integration. Although previously described in small numbers, this represents the largest case series to date. HAL is a safe minimally invasive surgical option for larger tumours, including malignancies. The HAL technique may additionally offer a shorter learning curve for trainee adrenal surgeons.

Long-term trends in PBDEs in sparrowhawk (Accipiter nisus) eggs indicate sustained contamination of UK terrestrial ecosystems.

PBDE contamination in terrestrial biota is poorly characterized, and robust data on temporal trends are scarce. We measured temporal (1985-2007) and spatial trends in PBDE contamination in the eggs of the sparrowhawk (Accipiter nisus), a sentinel for the terrestrial environment. Five BDEs were the most abundant (BDE 99 > 47 > 153 > 100 > 154). Their concentrations, and that of the sum PBDEs (ΣPBDE), increased from the mid-1980s, peaking in the midlate 1990s at levels that were sustained until the end of the study. This and the predominance of BDE99 contrast with patterns in piscivorous species and suggest sparrowhawks, and perhaps terrestrial species more widely, may be relatively poor metabolizers of penta-BDEs. BDE 196, 197, 201, and 203 concentrations increased linearly through the study, indicating increasing contamination possibly from the presence of these congeners in, and/or debromination of, deca-BDE formulations. Variation in egg ΣPBDE concentration was not explained by % urban land cover, human population density or % of arable land in proximity to the nest site, or by land use. Overall, egg ΣPBDE concentrations (34-2281 ng/g wet weight) were some of the highest reported in birds from Europe. We found no relationship between ΣPBDE concentrations and eggshell thickness.

Isolation of Angola-like Marburg virus from Egyptian rousette bats from West Africa.

Marburg virus (MARV) causes sporadic outbreaks of severe Marburg virus disease (MVD). Most MVD outbreaks originated in East Africa and field studies in East Africa, South Africa, Zambia, and Gabon identified the Egyptian rousette bat (ERB; Rousettus aegyptiacus) as a natural reservoir. However, the largest recorded MVD outbreak with the highest case-fatality ratio happened in 2005 in Angola, where direct spillover from bats was not  shown. Here, collaborative studies by the Centers for Disease Control and Prevention, Njala University, University of California, Davis USAID-PREDICT, and the University of Makeni identify MARV circulating in ERBs in Sierra Leone. PCR, antibody and virus isolation data from 1755 bats of 42 species shows active MARV infection in approximately 2.5% of ERBs. Phylogenetic analysis identifies MARVs that are similar to the Angola strain. These results provide evidence of MARV circulation in West Africa and demonstrate the value of pathogen surveillance to identify previously undetected threats.

Single stage hand assisted laparoscopic and trans thoracic excision of multifocal paraaortic and cardiac paragangliomas.

A 26-year-old male, with a family history of Paraganglioma Syndrome 4 (PGL4) presented with an 18-month history of paroxysmal headaches, a one-month history of frequent diaphoresis, anxiety attacks and unintentional weight loss of one stone in 2 months. Physical examination and vital parameters were normal. Laboratory studies showed significant elevation of plasma normetanephrines and 3-methoxytyramine while DNA molecular analysis confirmed pathogenic mutation in the SDHB gene and genetic transmission of PGL4. Imaging studies demonstrated a left para-aortic mass in the mid-abdomen and a mediastinal paraganglioma between the root of aorta and origin of the main pulmonary artery, encroaching the right ventricle. After adequate alpha blockade, the patient underwent a combined sequential hand-assisted laparoscopic resection of the abdominal tumour followed by midline sternotomy and resection of the second lesion at the root of the aorta, complicated by the need for emergency cardiopulmonary bypass due to perforation of right ventricular wall.

Predictors of Hypertension in a Population of Undergraduate Students in Sierra Leone.

We report on the first survey of hypertension in undergraduates in Sierra Leone. Levels of hypertension (12%) and obesity (4%) appear low compared to the general population but given the rapid increase of both and the expectation that many graduates will enter the formal employment sector and a sedentary lifestyle, there is still cause for concern. We measured their BMI (body mass index) and used a questionnaire to investigate demographic and lifestyle choices. In agreement with most authorities, we found that BMI and age were statistically significant predictors of systolic and diastolic blood pressure but that the explanatory power was low (r = 0.21 to 0.27). Men may be more sensitive than women to an increase in BMI on blood pressure (p < 0.1). We failed to find statistically significant relationships with ethnicity, religion, stress, course of study, levels of physical activity, diet, smoking, or consumption of caffeine and alcohol. Family history of hypertension, consumption of red palm oil, and self-diagnosed attacks of typhoid fever were close to conventional levels of significance (p < 0.1). We intend to use this as a baseline for longitudinal studies to assess risks and suggest appropriate public health action.

Closing the loop: a spatial analysis to link observed environmental damage to predicted heavy metal emissions.

In many cases, the link between industrial emissions and damage to the environment can only be inferred. The Environment Agency of the United Kingdom imposes emissions limits on industrial sites so that predicted concentrations and deposition rates remain below standard thresholds. Estimates of appropriate critical levels and loads are usually based on laboratory results and rarely estimate synergistic effects between pollutants or consider biological adaptation or selection in the target receptor organisms. The Avonmouth smelter has been emitting zinc and other heavy metals since 1929. It has been the subject of a number of detailed and synoptic studies, especially the impact on soil invertebrates. Damage was assessed using both physiological and ecological measurements. Two methods of spatial analysis were investigated, namely interpolation using standard geographical information system (GIS) operators and atmospheric dispersal modeling using an off-the-shelf model. Both methods can be used to compute contours (isolines) of predicted biological effect. Correlation results show that dispersal modeling is at least as good as kriging but requires much less data. This article demonstrates the usefulness of GIS and dispersal models as tools in decision making to determine the most suitable sampling sites in the assessment and monitoring of the impact of contamination around major point sources.

Identifying pollution hot spots from polychlorinated biphenyl residues in birds of prey.

Techniques for determining whether patterns of points are random, clustered, or dispersed are well established; however, when the magnitude of the attribute at each location is also important, the situation is more problematic. The concentration of polychlorinated biphenyls (PCBs) in the livers of Eurasian sparrowhawks Accipiter nisus and common kestrels Falco tinnunculus has been determined for birds from all over Great Britain for several decades and forms a unique database. When mapped, there appears to be clusters of high values in some parts of the country. If these clusters are truly significant, then they may indicate pollution hot spots and possibly help identify undocumented sources of contamination. What constitutes a cluster is open to debate. We know something about the foraging behavior of birds of prey, but we do not know how many pollution sources (hot spots) there are, how long they persist, or over what area they may disperse PCBs. We used a Monte Carlo simulation approach to determine whether the visually prominent clusters of high PCB residues were significant features or merely illusions. The five largest nonoverlapping clusters (defined in terms of the total PCB concentration) were identified at a range of spatial scales. In addition to the total concentration and the number of observations, the weighted centroid of the clusters and which individual birds were involved were also recorded. This enabled us to determine the scale over which the candidate hot spot was stable. Comparing the magnitude of the observed clusters with those from the trial simulations determined the probability of nonrandomness in the original data set (at each spatial scale). Results showed that some clusters do exist but, in the majority of cases, apparent clusters identified by eye could not be considered an actual aggregation of high concentrations following spatial analysis.

Intraoperative hyperkaliemia complicating hand-assisted live-donor nephrectomy.

OBJECTIVES: Live donation has become increasingly valuable as a potential source of kidneys for transplant with hand-assisted laparoscopic donation is an important method of organ procurement. An important consideration is adequate preoperative and intraoperative planning, and precautions to minimize potential risks in the donor while providing a graft with good primary function. MATERIALS AND METHODS: We present a case of live donation in which a hand-assisted laparoscopic approach was used to facilitate kidney donation. The process was complicated by a period of profound intraoperative hyperkalaemia, subsequently ascribed to rhabdomyolysis owing to muscle necrosis. RESULTS: A 46-year-old man underwent assessment for live kidney donation for his brother. Preoperative investigations revealed normal renal function with no contraindications to donation. However, at the time of donation, a period of unexplained hyperkalaemia occurred that resolved spontaneously with fluid resuscitation and aggressive diuresis. After surgery, he was demonstrated to have an elevated creatine kinase level associated with unilateral gluteal pain and bruising. There were no long-term complications, and the donor made a full recovery with normal renal function. Hyperkalaemia was ascribed to extensive rhabdomyolysis owing to positioning on the operating table at the time of surgery. CONCLUSIONS: Rhabdomyolysis associated with laparoscopic renal surgery requires prompt recognition and treatment while unexplained hyperkalaemia may herald its onset. It is important that an increased sense of vigilance is given to patients with increased muscularity or body mass, especially in donor nephrectomy patients, because of its effect on the remaining solitary kidney.

Outdoor and indoor cadmium distributions near an abandoned smelting works and their relations to human exposure.

The relationship of measured or modelled Cd concentrations in soil, house dust and available to plants with human urinary Cd concentrations were assessed in a population living around a Cd/Pb/Zn smelter in the UK. Modelled air concentrations explained 35% of soil Cd variation indicating the smelter contributed to soil Cd loads. Multi-variate analysis confirmed a significant role of biological and life-style factors in determining urinary Cd levels. Significant correlations of urinary Cd with soil, house dust and modelled plant available Cd concentrations were not, however, found. Potential reasons for the absence of clear relationships include limited environmental contact in urban populations; the role of undefined factors in determining exposure; and the limited spatial scope of the survey which did not sample from the full pollution gradient. Further, the absence of any significant relationship indicates that environmental measures provide limited advantage over atmospheric model outputs for first stage human exposure assessment.

Comparing statistical and semantic approaches for identifying change from land cover datasets.

In this paper, we examine methods for integrating spatial data which apparently should be comparable because they are of the same data type or theme, but which are incompatible or discordant because the classes of that theme are different. For a variety of reasons including changes in methods, in understanding of the resource, and in policy initiatives in the commissioning of the survey, this problem is widespread in the results of natural resources surveys. We present two generic methods: one method is grounded in a statistical approach using discriminant analysis, and the other exploits the knowledge of experts. We use the context of land cover mapping of Great Britain to explore these approaches for integrating discordant data. We demonstrate that the expert-based approach gives very good levels of identification of locations with incompatible classifications at different times, and gives a much better rate of recognition of change. Some conclusions are made about the need to expand current metadata and data quality reporting to include descriptions of:- data conceptualisations, semantics and ontologies;- who decided and defined what the features of interest in a dataset are, and why. If the benefits of spatial data initiatives such as GRID, E-science and INSPIRE are to be fully realised then some method needs to be found to communicate that information most effectively to the potential user of the data.