Revising a laparoscopic appendicectomy set to reduce reliance on disposable surgical instruments: supporting the transition to sustainable surgical practice.

INTRODUCTION: After excluding anaesthetic gases, around one-third of carbon emissions from surgical procedures are from consumables. This sustainable quality improvement project revised the laparoscopic appendicectomy surgical set at a large teaching hospital, with the aim of reducing unnecessary usage of disposable laparoscopic ports and surgical instruments. METHODS: A prospective audit of 25 consecutive laparoscopic appendicectomies (5% of annual appendicectomies performed at the Trust) was conducted to assess use of disposable instruments. The financial and environmental costs of the five most commonly used disposable instruments were calculated and annual cost of current practice determined. A revised surgical set was created to include additional reusable instruments and new reusable ports. A reaudit of disposable surgical instrument usage was conducted and the financial and environmental impact of the new set compared with the results from the initial audit. RESULTS: A total of 109 disposable instruments were opened in 25 appendicectomies, costing an estimated £49,656 and 692kg CO2 equivalent (CO2e) annually. Following rollout of the revised appendicectomy set, there was a significant reduction in disposable instrument usage (median four versus one instruments per case, p<0.00001). The revised set is predicted to reduce annual disposable instrument usage from 2,180 to 705 instruments (68% reduction), saving £219,452 and 3.02 tonnes CO2e over the estimated seven-year lifecycle of the reusable instruments. CONCLUSIONS: Updating a laparoscopic appendicectomy set to include additional/new reusable instruments can lead to a marked reduction in disposable surgical instrument usage. This results in significant projected financial and CO2e savings.

Inadvertent vesicular placement of a vaginal contraceptive ring presenting as persistent cystitis.

BACKGROUND: The NuvaRing is a soft, flexible, ring-shaped vaginal contraceptive device that is placed by the user herself. Incorrect placement has not been described, because any intravaginal position allows appropriate hormonal delivery through the vaginal mucosa. CASE: A 22-year-old otherwise healthy woman presented with 2 months of urinary urgency, frequency, and pelvic pain, which were unresponsive to antibiotic therapy. Her symptoms began immediately after placement of a NuvaRing vaginal contraceptive device, which she was subsequently unable to locate. Thorough evaluation revealed the ring in the urinary bladder. CONCLUSION: Bladder or urethral foreign body should be considered in the evaluation of patients with chronic cystitis, especially if the patient uses vaginal medical devices. Intravesicular placement of a device may occur even without psychiatric or physical comorbidities.

Age has a profound effect on the incidence and significance of chromosome abnormalities in myeloma.

A simple high throughput micro-fluorescence in situ hybridisation technique (FISH) was used to detect chromosome 13 deletions (delta13), immunoglobulin heavy chain (IgH) rearrangements, t(11;14)(q13;q32), t(4;14)(p16;q32), t(14;16)(q23;q32), p53 loss, and numerical changes of chromosomes 3, 6, 7, 9, 10, 11 and 17 in 228 cases of multiple myeloma (MM), including 33 asymptomatic/smouldering MM (SMM). The patients were not part of a clinical trial and were from 30 different hospitals. In all, 98.4% of cases were abnormal, with 43% having IgH rearrangements and 42% Delta13. The low incidence of IgH rearrangements was due to a decrease in this finding with age (P = 0.001) and the relatively high proportion of elderly patients in our study population (41% >70 years old). The incidence of specific IgH translocations was t(4;14) 11%, t(11;14) 16% and t(14;16) 3%. Univariate statistical testing showed delta13 (P = 0.002), and t(14;16) (P = 0.005) to be associated with shorter survival. This effect was exaggerated for patient's aged 70 years or under but no effect on survival was seen for those over 70 years. In younger patients t(4;14) (P = 0.044) and p53 deletion (P < 0.001) were also significant poor prognostic indicators. Multivariate analysis showed delta13 and t(14;16) to be independent prognostic variables when considered with age and clinical parameters.

Role of residue Y99 in tissue plasminogen activator.

The crystal structure of the fibrinolytic enzyme tissue plasminogen activator (tPA) shows that the bulky side chain of Y99 hinders access to the active site by partially occluding the S2 site and may be responsible for the low catalytic activity of tPA toward plasminogen. We have tested the role of Y99 by replacing it with Leu, the residue found in more proficient proteases like trypsin and thrombin. The Y99L replacement results in an increase in the k(cat)/Km for chromogenic substrates due to enhanced diffusion into the active site. The increase is modest (threefold) for substrates specific for tPA that carry Pro or Gly at P2, but reaches 80-fold for less specific substrates carrying Arg at P2. On the other hand, the Y99L mutation has no effect on the activity of tPA toward the natural substrate plasminogen, that carries Gly at P2, and reduces more than 10-fold the inhibition of tPA by plasminogen activator inhibitor-1 (PAI-1), that carries Ala at P2. We conclude that the steric hindrance provided by Y99 in the crystal structure affects mostly nonphysiological substrates with bulky residues at P2. In addition, residue Y99 plays an active role in the recognition of PAI-1, but not plasminogen. Mutations of Y99 could therefore afford a resistance to inhibition by PAI-1 without compromising the fibrinolytic potency of tPA, a result of potential therapeutic relevance.

Spatial and temporal aspects of the genetic structure of Juniperus communis populations.

Juniperus communis is a dioecious, wind pollinated shrub or small tree that produces 'berries' (female cones) containing a small number of seeds that are thought to be dispersed by birds. The expectation, therefore, would be that populations of Juniper are genetically diverse with little structuring between them. In Britain, the species has two main centres of distribution: a highland zone in the north and west, in which populations are still large and sexually reproducing, and a southern zone on chalk downlands in which populations are small and fragmented and individuals suffer from a decline in fertility. Thus, one would expect the large sexually viable populations in the north to exhibit high levels of within-population genetic variation, while the declining southern populations would be genetically depauperate. The analysis of amplified fragment length polymorphisms (AFLPs) was used to test this hypothesis. Surprisingly, all populations studied showed high levels of genetic variation although there was clear structuring between populations. On the basis of the geographical structuring of the populations it was hypothesized that J. communis colonized Britain via three separate routes.

Analysis off cereal chromosomes by atomic force microscopy.

Atomic force microscopy has been applied to the study of plant chromosomes from cereal grasses Triticum aestivum (bread wheat), Triticum tauschii, and Hordeum vulgare (barley). Using standard mitotic metaphase squashes, high resolution images have been obtained of untreated chromosomes and also of chromosomes after C-banding, N-banding, and in situ hybridization. The true 3-dimensional nature of the images permits detailed analysis of the surface structure and, on untreated uncoated chromosomes, surface features on a length scale consistent with nucleosome structures have been observed. C+ and N+ regions are manifest as areas of high relief on a slightly collapsed chromosome structure. In situ hybridization leads to a more severe degradation of the native structure, although it is still possible to correlate the optical signal with the topography of the hybridized chromosome. Key words : atomic force microscope, AFM, chromosomes, C-banding, in situ hybridization.

A comparative study of the mitochondrial genome organization in in vitro cultures of diploid, tetraploid, and hexaploid Triticum species.

Southern-blot hybridizations of total DNA to mitochondrial DNA (mtDNA) probes were used to investigate the extent of mtDNA variability in cultures derived from immature embryos of diploid (Triticum monococcum, genomic formula: AA, T. tauschii, genomic formula: DD), allotetraploid (T. durum cv "Creso", genomic formula: AABB), and allohexaploid (T. aestivum, genomic formula: AABBDD) wheat species. Similar distinct changes in mtDNA organization were observed in in vitro cultures of the derived tetraploid and the hexaploid species with related genomes. The tetraploid and hexaploid species share the B genome and mtDNA variability in in vitro culture is known to be under nuclear control. These results suggest that a study of B genome diploids and other polyploid combinations would now shed light on whether or not mtDNA variability in tissue cultures is under B-genome control.

Nonrandom chromosome variation and morphogenic potential in cell lines of bread wheat (Triticum aestivum L.).

A cytogenetical analysis of 18 cell lines, 9 microspore derived, 6 anther derived, and 3 immature-embryo derived, of bread wheat (Triticum aestivum L.) varying in their morphogenic potential was undertaken. Chromosome variation, both structural and numerical, was detected in all lines studied. Variation was present and, in some cases quite extensive, in the earliest samples taken (only 12 weeks after initiation of the suspensions). Within any culture, the pattern and extent of variation changed throughout the course of the study and cells with a euploid constitution generally decreased in frequency with culture age. Among the nine microspore-derived suspensions, morphogenic lines generally showed a more restricted range of chromosome numbers and higher proportions of euploid cells than nonmorphogenic lines. The patterns of distribution of chromosome numbers among the anther-derived cultures were similar to those of the microspore-derived lines but the correspondence between instability and regenerative capacity was less. The immature embryo derived lines, which were neither regenerable nor morphogenic, were all unstable. The anther-derived lines were sampled over several months to determine whether loss of morphogenic potential was related to changes in chromosome instability of specific lines. Analysis of the "elite" line Fl.7, initially capable of regenerating green plants, showed that substantial decreases in the frequencies of normal euploid cells (from 45 to 5%) occurred over the period when morphogenic capacity was lost. However, whether the chromosome instability resulted in loss of morphogenicity or vice versa was not clarified. C-banding analyses of lines Fl.7 and C82d indicated that instability was not random with respect to the three genomes (A, B, and D) of wheat nor to the different chromosomes within the genomes. Chromosomes of the B genome were most often lost or involved in rearrangements, with breakpoints located at, or near, the heterochromatic blocks. Because of the heterogeneity of the cell lines, extensive analyses of large numbers of cells would be required before it would be possible to determine whether loss of morphogenic potential arises as a result of specific chromosome loss(es).

Chromosome 5D instability in cell lines of Triticum tauschii and morphological variation in regenerated plants.

Immature embryos of Triticum tauschii cultured on L2 medium with 30 g∙L−1maltose gave rise to compact and highly structured callus that readily regenerated shoots when transferred to MS medium supplemented with zeatin and indole-3-acetic acid. Two cell suspensions were initiated from the callus induced on L2 medium. An analysis of chromosome number in these cell suspensions after 3 months of culture showed that 95 and 75% of the cells had a normal complement. After 5 months, in both lines the majority of cells had chromosome complements of 2n = 13 and many of these aneuploid cells possessed a dicentric chromosome. C-banding indicated that the dicentric was often formed from chromosomes 2D and 5D. Fifty-six plants regenerated from callus were grown to maturity. Variation was observed in tiller number, flowering time, and seed-set; in two cases, the variation in early flowering was shown to be heritable. All the regenerants analysed had normal chromosome counts (2n = 2x = 14) and meiotic analyses of 35 plants revealed no obvious structural rearrangements.

Atomic force microscopy of plant chromosomes.

Atomic force microscopy has been used to image plant chromosomes from standard preparations without staining or coating. This has enabled the collection of high-resolution three-dimensional data on surface structure. The technique has been further applied to the imaging of C-banded chromosomes revealing structural changes resulting from the banding treatment. The bands were observed as localized areas of high relief.