Surgical innovation revisited: A historical narrative of the minimally invasive "Agarwal sliding-clip renorrhaphy" technique for partial nephrectomy and its application to an Australian cohort.

Objective: To evaluate local clinical outcomes of sliding clip renorrhaphy, from inception to current utilization for open, laparoscopic, and robotically assisted partial nephrectomy. Methods: We reviewed prospectively maintained databases of three surgeons performing partial nephrectomies with the sliding-clip technique at teaching hospitals between 2005 and 2019. Baseline characteristics, operative parameters, including surgical approach, RENAL Nephrometry Score, and post-operative outcomes, including Clavien-Dindo classification of complications, were recorded for 76 consecutive cases. We compared perioperative and 90-day events with patient and tumor characteristics, stratified by operative approach and case complexity, using Wilcoxon rank-sum test for continuous variables and the Chi-squared or Fisher's exact test, for binary and categorical variables, respectively. Results: Open surgery (n = 15) reduced ischemia time and operative time, but increased hospital admission time. Pre- and post-operative estimated glomerular filtration rates did not change significantly by operative approach. Older patients (P = .007) and open surgery (P = .003) were associated with a higher rate of complications (any-grade). Six grade ≥3 complications occurred: these were associated with higher RENAL Nephrometry Score (P = .016) and higher pathological tumor stage (P = .045). Limits include smaller case volumes which incorporate the learning curve cases; therefore, these data are most applicable to lower volume teaching hospitals. Conclusion: The sliding-clip technique for partial nephrectomy was first described by Agarwal et al and has low complication rates, acceptable operative time, and preserves renal function across open and minimally invasive surgeries. This series encompasses the initial learning curve with developing the technique through to present-day emergence as a routine standard of practice.

The Success and Evolution of a Urological "Boot Camp" for Newly Appointed UK Urology Registrars: Incorporating Simulation, Nontechnical Skills and Assessment.

BACKGROUND: Urological training has dramatically changed in recent years. Training durations are shorter and a drive toward consultant led care has reduced trainees experience. Within the UK, approximately 50 registrars annually embark on a 5-year Urology training programme, with variable levels of basic urological experience. OBJECTIVE: To describe a simulation programme aimed at delivering the knowledge and skills necessary to safely and effectively start working as a registrar in Urology by intensive training with a 1:1 faculty to delegate ratio. DESIGN, SETTING, AND PARTICIPANTS: Our course content mirrors the UK training syllabus for junior Urology registrars. We delivered 8 modules over a 4-day programme with a fifth day of assessments. Delegates level of urological knowledge, operative competency and confidence pre-, immediately post-training and at 3-months postcourse were assessed. Objective delegate and faculty feedback was also collected. Technical skills modules include; inguinoscrotal surgery, ureteroscopy, transurethral resection, urodynamics, and Botox administration as well as basic reconstructive and laparoscopic operative skills. "Nontechnical" skills included simulated ward round, out-patient, and emergency scenarios. RESULTS: Feedback from delegates and faculty members has been overwhelmingly positive. We have used this feedback to tailor the content of the course for following years. An increased knowledge level (based on mean examination scores [precourse 55.5%, postcourse 70.1%]) and operative competency was observed in all skills assessed (transurethral resection of the prostate, transurethral resection of bladder tumor, Ureteroscopy, laparoscopic skills, and instrument assembly). Operative confidence was increased immediately and at 3-months postcourse. CONCLUSIONS: Our "boot camp" course provides a realistic introduction and foundation to begin Urological practice. Being delivered at the beginning of the training scheme, prior to intensive patient exposure, registrars are in an optimum position to develop their newly acquired knowledge and skills to enhance training and intends to improve patient safety and satisfaction.

Prospective use of unmanned aerial vehicles for military medical evacuation in future conflicts.

In order to continue to deliver outstanding medical care on the battlefield, the UK Defence Medical Services must continue to adapt, overcome and actively embrace change. One potential area is the rapid proliferation and sophistication of automated and remote systems such as unmanned aerial vehicles (UAVs). UAVs are already used to deliver blood to remote military locations in Afghanistan and defibrillators to those that need them in the USA and Sweden. An area of future opportunity would be to facilitate rapid evacuation of wounded personnel from high intensity, high threat, remote and austere areas directly to specialist care. Such a capability would reduce threat to human life while allowing rapid extraction of casualties from high risk or inaccessible environments straight back to Role 3 care, all of which in these situations is either not possible or carries too much risk using conventional aerial assets. The article aims to highlight a potential future capability, stimulate debate and reflection, all of which is essential for innovation and future organisational development. The potential uses and benefits of UAVs are highlighted including both the challenges and rewards of utilising UAVs for casualty evacuation. Key benefits are reduced risk to human life, cost, ability to insert into areas conventional aircraft cannot and the rapidity of transfer. Challenges are likely to be airspace management, decisions on appropriate level of care to deliver during transit and ultimately user acceptability. The article also highlights that in order to maximise our ability to exploit new technologies, all arms and trades within the military must be involved in collective research and development. Furthermore, sensible corroboration with private companies will further enhance our ability to acquire products that best serve our needs.

Characterization of rhizosphere fungi from selenium hyperaccumulator and nonhyperaccumulator plants along the eastern Rocky Mountain Front Range.

PREMISE OF STUDY: Selenium-hyperaccumulator plants can store over 1% (dry mass) Se in their tissues, despite the toxicity of this element at high concentrations across eukaryotes. These levels of Se can have widespread effects on the plant's ecological partners, including herbivores and pathogens. Still other partners seem to have coevolved Se tolerance. This is the first known study addressing the rhizosphere mycoflora of Se hyperaccumulators and aims to evaluate the rhizospheric fungal diversity and Se tolerance to further the knowledge of how these organisms interact with their host plants and survive in these extreme habitats. METHODS: Rhizosphere fungi were isolated from Se-hyperaccumulator and nonaccumulator plant species collected from five sites in Colorado and Wyoming; four seleniferous sites and one nonseleniferous site. 259 isolates were identified to genus or species and evaluated for Se tolerance. KEY RESULTS: Among the 24 represented genera, 11 comprised 86% of the isolates. The majority of isolates from the seleniferous sites were unaffected by 10 mg·L(-1) Se, irrespective of host plant (hyperaccumulator vs. nonaccumulator), while rhizosphere fungi from a control, nonseleniferous site were highly sensitive to Se at 10 mg·L(-1) and as a group were significantly less (α = 0.05) tolerant than the isolates from the seleniferous sites. CONCLUSIONS: Even though Se is a commonly used antifungal agent, these results suggest that rhizosphere fungi from seleniferous habitats have widespread Se tolerance, likely an adaptive advantage in their Se-rich habitat.

Secretory leukocyte protease inhibitor, an inhibitor of neutrophil activation, is elevated in serum in human sepsis and experimental endotoxemia.

OBJECTIVES: To document changes in serum secretory leukocyte protease inhibitor (SLPI) in human sepsis and in experimental endotoxemia in vivo. To compare changes in serum SLPI in human sepsis with changes in interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-alpha. To determine whether or not changes in SLPI correlate with the severity of multiple organ dysfunction syndrome as measured by the maximal multiple organ dysfunction score. Finally, because neutrophils have been implicated in tissue injury associated with organ dysfunction, to determine whether recombinant human SLPI blocks activation of isolated human neutrophils. DESIGN: Case-control study and ex-vivo cellular assay. SETTING: Surgical intensive care unit and clinical research center of university hospitals; laboratory of a medical school. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There was a significant dose-dependent elevation (50.2+/-4.0 ng/mL, p = .01) in plasma SLPI 12 hrs after administration of lipopolysaccharide to seven healthy adults (36.4+/-2.3 ng/mL). Further, serum concentrations of SLPI (132+/-15 ng/mL) were elevated in septic surgical patients compared with healthy controls (43+/-2 ng/mL, p < .01) and nonseptic surgical controls (69+/-10 ng/mL, p = .01). Serum SLPI concentrations correlated (r2 = .71, p < .01) better with organ dysfunction as measured by maximal multiple organ dysfunction score than did serum IL-6 (r2 = .49, p < .01), IL-10 (r2 = .05, p = .22), or TNF-alpha (r2 = .02, p = .44). We found that recombinant human SLPI in vitro inhibits TNF-alpha-induced hydrogen peroxide production by human neutrophils (ID50 = 1-2 microg/mL). CONCLUSIONS: Serum SLPI is elevated in human sepsis and experimental endotoxemia. Maximal concentrations of serum SLPI correlate significantly with maximal multiple organ dysfunction scores in patients with sepsis. Secretory leukocyte protease inhibitor may function to limit ongoing neutrophil-mediated tissue injury associated with organ dysfunction.

Induction of antisense Pax-3 expression leads to the rapid morphological differentiation of neuronal cells and an altered response to the mitogenic growth factor bFGF.

Mutations within the Pax-3 gene lead to a range of developmental abnormalities in both humans and mice. In this report, we have investigated the role that Pax-3 plays in neuronal cell development by specifically downregulating Pax-3 expression within a neuronal cell line. This was achieved by stably transfecting the neuronal cell line ND7 with an expression vector in which antisense Pax-3 RNA was produced under the control of the inducible MMTV promoter. In the stable transfectants, we found that the addition of dexamethasone led to the induction of antisense Pax-3 RNA and a rapid downregulation in endogenous Pax-3 protein expression. The decrease in endogenous Pax-3 protein expression corresponded with a dramatic change in the morphology of the cell: the normally rounded ND7 cells exhibited increased cell to substrate adhesion, extended long neurite processes and expressed genes such as snap-25 that are characteristic of a mature neuron. The morphological differentiation induced by a reduction in Pax-3 expression was followed 24-48 hours later by a cessation in cell proliferation. Interestingly the morphological differentiation and cessation in cell proliferation inducted in the cell lines lacking Pax-3 could be reversed by the addition of the mitogenic growth factor EGF but not by bFGF, whose receptor was downregulated in these cells. These results suggest that the expression of Pax-3 is essential to maintain the undifferentiated phenotype of these immature neuronal cells, and in its absence the cells acquire many of the characteristics of a mature neuronal cell. The slow onset of cell cycle arrest in the cells lacking Pax-3 argues against this transcription factor playing a direct role in the regulation of neuronal cell proliferation.

Anesthetic techniques and positioning: implications for perioperative nurses.

Depending on the anesthetic technique used and the position in which the patient is placed, the perioperative nurse knowledgeable in the implications of each technique will positively impact patient safety and management. This involves a thorough understanding of the systems affected and associated risks. Whether general anesthesia, regional anesthesia, or monitored anesthesia care is provided, specific actions by the nurse facilitates teamwork.

The DNA binding activity of the paired box transcription factor Pax-3 is rapidly downregulated during neuronal cell differentiation.

Mutations in the murine Pax-3 gene lead to a range of developmental abnormalities including deficiencies in sensory and sympathetic neurones. We have investigated Pax-3 expression during neuronal differentiation and show levels of Pax-3 DNA binding decrease upon cell cycle arrest and morphological differentiation. The fall in Pax-3 DNA binding occurs within 1 h of the induction of differentiation and is mediated in part by a decrease in Pax-3 mRNA. This decrease in Pax-3 binding activity precedes any changes in cell proliferation or morphology, suggesting that the downregulation of this transcription factor may be an important prerequisite for the differentiation of neuronal progenitor cells.

Percutaneous transluminal angioplasty in coronary-internal thoracic-subclavian steal syndrome.

Internal thoracic artery implants are widely used as conduits in coronary artery bypass surgery because of their resistance to the development of atherosclerosis. Two cases are reported of subclavian artery stenosis proximal to the internal mammary artery in patients who had undergone coronary bypass surgery. In both cases, an atypical pattern of postsurgical angina developed, with retrosternal chest pain occurring specifically with upper extremities exercise. Coronary and graft angiography revealed retrograde flow in the left internal thoracic artery during injection of the grafted coronary. Severe stenosis was identified in the subclavian artery. Treatment consisted of dilation of the subclavian artery stenosis with stent placement in one patient. Both patients had marked symptomatic improvement after the procedure.

Comparative diagnostic accuracy of Tl-201 and Tc-99m sestamibi SPECT imaging (perfusion and ECG-gated SPECT) in detecting coronary artery disease in women.

OBJECTIVES: This prospective study was conducted in 115 women to directly compare the sensitivity and specificity of thallium-201 (Tl-201), technetium-99m (Tc-99m) sestamibi perfusion and Tc-99m sestamibi electrocardiographic (ECG)-gated single-photon emission computed tomographic (SPECT) studies for detection of coronary artery disease (CAD). BACKGROUND: Data on the comparative diagnostic accuracy of Tl-201 and Tc-99m sestamibi perfusion imaging for the detection of CAD, specifically in women, are very limited. METHODS: Eighty-five patients with suspected CAD, scheduled for coronary angiography, and 30 volunteers with a pretest likelihood of < or = 5% for CAD were evaluated. Within 1 week, each patient underwent Tl-201 and Tc-99m sestamibi SPECT imaging procedures (both perfusion and gated SPECT imaging). Treadmill stress testing was used in 78 patients and dipyridamole in the remaining 37 patients. All images were interpreted by three observers in a blinded manner (consensus reading). Technetium-99m sestamibi SPECT studies were read without and then with ECG gating. Technetium-99m sestamibi gated SPECT studies were used to differentiate scar tissue from soft tissue attenuation artifact. RESULTS: The overall sensitivities for detecting > or = 50% and > or = 70% stenoses were 75.0% and 84.3%, respectively, for Tl-201, and 71.9% and 80.4%, respectively, for Tc-99m sestamibi perfusion studies (p = 0.48). The specificity for lesions > or = 50% was 61.9% for Tl-201 and 85.7% for Tc-99m sestamibi perfusion (p = 0.07), whereas for lesions > or = 70% it was 58.8% for Tl-201 and 82.4% for Tc-99m sestamibi perfusion (p = 0.01). When the 34 patients with a normal coronary angiogram were added to the group of 30 normal volunteers, the "specificity" for lesions > or = 70% was 67.2% for Tl-201, 84.4% for Tc-99m sestamibi SPECT perfusion (p = 0.02) and 92.2% for Tc-99m sestamibi gated SPECT (p = 0.0004). CONCLUSIONS: Both Tl-201 SPECT and Tc-99m sestamibi SPECT perfusion studies had a similar sensitivity for the detection of CAD in women. However, Tc-99m sestamibi SPECT perfusion imaging shows a significantly better specificity, which is further enhanced by the use of ECG gating.

Long-term angiographic follow-up after angioplasty of venous coronary bypass grafts.

From April 1981 to June 1987, 57 patients underwent venous coronary bypass graft percutaneous angioplasty and had a minimal follow-up of 18 months. The procedure was elective for 28 patients, urgent for 19, and was considered as an emergency for 10. A total of 64 grafts were dilated that had been bypassed 58 +/- 48 months previously (range 2 to 184 months); lesions were located on the aortic anastomosis in 12 grafts, on the body in 38, and on the coronary anastomosis in 14. Technical success was 95.3% (61 of 64) per lesion; clinical success was 84.4% (54 of 64) per lesion and 82.5% (47 of 57) per patient. Thrombotic complications with images of a lacunar defect occurred in 11 grafts (17.2%). Predictive factors for these complications were: age of grafts 38.5% for greater than 60 month grafts versus 2.6% for less than 60 month grafts (p less than 0.01); site of lesion, body lesion 28.9% versus anastomosis none (p less than 0.01); type of lesion, concentric and short 6% versus other 29% (p less than 0.05); and recent fibrinolysis in 66% versus 10.6% (p less than 0.05). Long-term follow-up is available in the 47 successful patients and the three limited non-Q wave myocardial infarction patients. Two patients died at 13 and 17 months. Long-term angiographic follow-up is available in 45 of 48 patients or 94%. At the end of the study, 35 of 57 (61.4%) venous bypass grafts in 32 patients (64%) were patent after one or more percutaneous transluminal angioplasties.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors predicting mortality in idiopathic dilated cardiomyopathy.

A study of factors predicting mortality was performed in 201 patients with dilated cardiomyopathy (163 men, 38 women, mean age: 48 +/- 11 years) by multivariate analysis (Cox Model) of 51 clinical, electrocardiographic, echocardiographic and haemodynamic parameters, 56 patients died during follow-up (mean follow-up: 57.1 +/- 29.9 months). 5 year survival was 77 +/- 3%. The following parameters were independent predictors of mortality: first symptom: pulmonary oedema, peripheral oedema, syncope; duration of symptoms at the time of inclusion; end systolic left ventricular volume; end diastolic left ventricular diameter; pulmonary artery systolic pressure; and their combination had the most accurate predictive value for death. A quantitative score (s) was calculated and used to define three subgroups: A:s less than or equal to 4.5; B: 4.5 less than s less than 6; C:s greater than or equal to 6. Five-year survival was 90 +/- 5% in group A; 84 +/- 4% in B and only 53 +/- 7% in C. In conclusion, overall survival was good in this population of all stage dilated cardiomyopathy; factors related to clinical severity, left ventricular dilation, systolic pulmonary artery pressure and duration of symptoms defined a subgroup of patients with poor prognosis.

Long term follow-up after portacaval shunt and internal mammary coronary bypass graft in homozygous familial hypercholesterolemia: report of two cases.

Homozygous familial hypercholesterolemia (HFH) is characterized by a very shortened lifespan, mainly due to cardiac events, and by resistance to conventional lipid lowering therapies. Two patients are described for whom a combination of portacaval shunt and mammary coronary bypass graft were done with good long term success. A review of the actual forms of treatment of HFH is made. To the authors' knowledge, there is no report in the literature of this double surgical approach.

Evidence of the inaccuracy of standard echocardiographic and angiographic criteria used for the recognition of true and "false" left ventricular inferior aneurysms.

Diagnosis of so-called false aneurysms of the left ventricle after infarction is judged to be important because the risk of rupture is high and resection of aneurysms with a narrow orifice is usually successful. Aneurysms with larger communication orifices are less likely to rupture. Echocardiographic and angiographic criteria have been devised to classify left ventricular aneurysms into two distinct types. In four cases of inferior aneurysms the echocardiographic and angiographic criteria were typical of a "false aneurysm" but the defects were diagnosed as true aneurysms after intraoperative and histological examination. These aneurysms were characterised by their site in the inferior wall and by late diagnosis and treatment, which may have influenced their occurrence and determined the development of their characteristic shape. These findings suggest that the classic echocardiographic and angiographic diagnostic criteria for "false" aneurysms may have to be abandoned.