Surgery under siege: A case study of leg amputation in 18th century Louisbourg, Nova Scotia, Canada.

OBJECTIVE: Paleopathological analysis of a below-knee amputation was conducted to explore the sociocultural reasons why the amputation took place. MATERIALS: Older adolescent male (18-21 years) from the New Englander mass burial at the 18th century Fortress of Louisbourg. METHODS: Macroscopic assessment and archival data. RESULTS: A surgical amputation of the right tibia and fibula, distal to the knee was identified. The cross-sectional diaphysis of the leg has kerf marks and a splinter (breakaway point) at the posterior-lateral border of the tibia suggesting the leg gave way from its own weight or was manually removed once most of the sawing was complete. CONCLUSIONS: Archival records suggest frostbite from prolonged exposure to freezing temperatures and trauma from unsafe working conditions at the Fortress were the main causes that led to amputation. SIGNIFICANCE: This case study highlights the importance of contextualizing cases of amputation to understand factors leading to the amputation procedure and techniques used in the past, and the social and living conditions of the individual. LIMITATIONS: Observations were restricted to skeletal material as soft tissue decomposed and there was no material evidence suggestive of amputation associated with this individual in their grave. SUGGESTIONS FOR FUTURE RESEARCH: Full trauma assessment of the Fortress of Louisbourg skeletal collection to provide additional insight into injury sustained at Louisbourg and 18th century surgical practices.

Implementing advance care plans in the peri-operative period, including plans for cardiopulmonary resuscitation: Association of Anaesthetists clinical practice guideline.

Contemporary guidance takes a patient-centred approach and recommends discussing and planning treatments that should be considered, not just those that should be withheld. Although some organisations and communities still use specific DNACPR (do not attempt cardiopulmonary resuscitation) forms to recommend that cardiopulmonary resuscitation is not attempted, this approach has been shown to have disadvantages and is no longer regarded as best practice. The following guidelines have been produced in response to this change. They are designed to help anaesthetists, as part of the wider healthcare team, to implement and respond to advance care planning documents before and during procedures. The guidelines apply to all procedures, however minor and low risk they are considered to be, and the same ethical and legal principles apply to procedures carried out under local or regional anaesthesia and/or conscious sedation, as well as to those under general anaesthesia.

Patient and disease factors predictive of adverse perioperative outcomes after nephrectomy.

INTRODUCTION: The aim of this study was to determine the patient and disease factors predictive of adverse perioperative outcomes after nephrectomy using the British Association of Urological Surgeons (BAUS) audit database. METHODS: All nephrectomies entered on the BAUS database for the year 2012 were included and ten patient or disease factors were selected for analysis. Logistic regression was used to calculate the area under the receiver operating characteristic curve (AUC) (0.5 = no better than chance, 1.0 = perfect prediction) for each variable and 500 bootstrap samples were used to determine variable selection. RESULTS: Data were captured for 6,031 nephrectomies in 2012. World Health Organization performance status (WHO-PS) (AUC: 0.733) and anaemia (AUC: 0.696) were the most significant predictors of 30-day mortality in univariate analysis. WHO-PS (AUC: 0.626) and anaemia (AUC: 0.590) also predicted complications classified as Clavien-Dindo grades III-V. Anaemia (AUC: 0.722) and clinical T stage (AUC: 0.713) predicted need for transfusion. CONCLUSIONS: Adverse perioperative outcomes after nephrectomy are predicted by clinical presentation with haematuria, poor WHO-PS and higher TNM (tumour, lymph nodes, metastasis) stage. This study used surgeon collected data as opposed to an administrative database, which may have advantages in terms of accuracy and breadth of data fields. These data form a basis for preoperative patient counselling and informed consent for nephrectomy. They can also be used as a standard against which surgeons and hospitals can compare their own results.

Kidney Transplantation Significantly Improves Patient and Graft Survival Irrespective of BMI: A Cohort Study.

Obesity and end-stage renal disease (ESRD) are on the increase worldwide. Kidney transplantation is the treatment of choice for ESRD. However, obesity is considered a contraindication for transplantation. We investigated the effect of BMI on mortality in transplanted and patients remaining on the waiting list in the United Kingdom. We analyzed the UK Renal Registry (RR) and the National Health Service Blood and Transplant (NHSBT) Organ Donation and Transplantation data for patients listed from January 1, 2004 to December 31, 2010, with follow-up until December 31, 2011. Seventeen thousand six hundred eighty-one patients were listed during the study period, with BMI recorded for 13 526 (77%). One- and five-year patient survival was significantly better in all BMI bands (<18.5, 18.5-<25, 25-<30, 30-<35, 35-<40, and 40+kg/m(2) ) in the transplant group when compared to those who remained on the waiting list (p < 0.0001). The analyses were repeated excluding live donor transplants and the results were essentially the same. On analyses of patient survival with BMI as a continuous variable or using 5 kg weight bands, there was no cut-off observed in the higher BMI patients where there would be no benefit to transplantation. For transplanted patients (N = 8088), there was no difference in patient or graft survival between the defined BMI bands. Thus, irrespective of BMI, patient survival is improved if transplanted.

Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram.

BACKGROUND: Clinical features may be used to determine which patients with suspected acute coronary syndrome (ACS), but a normal or non-diagnostic ECG, should be selected for further investigation or inpatient care. We aimed to measure the diagnostic value of clinical features for ACS. METHODS: Standardised data relating to presenting characteristics, associated features and risk factors were collected at seven chest pain units established for the ESCAPE trial. All patients received troponin measurement at least 6 h after last significant symptoms, creatine kinase MB(mass) gradient over 2 h and, if appropriate, treadmill exercise testing. The reference standard of ACS was defined as troponin >0.03 ng/ml, creatine kinase MB(mass) gradient >3.0 ng/ml or early positive treadmill exercise test. RESULTS: 1576 patients were analysed, including 132 (8.4%) with ACS. Patients with ACS were older, had longer symptom duration, were more likely to be a man, hypertensive and an ex-smoker or have pain radiating to their right arm. On multivariate analysis, only age, duration, sex and radiation of pain to the right arm were independently associated with ACS. Likelihood ratios (95% CI) were radiation of pain to the right arm, 2.9 (95% CI 1.4 to 6.3), male sex 1.2 (95% CI 1.0 to 1.3) and female sex 0.79 (95% CI 0.62 to 1.0). The area under the receiver operator characteristic curve for age was 0.629 (95% CI 0.573 to 0.686) and for duration was 0.546 (95% CI 0.481 to 0.610). CONCLUSION: Clinical features have very limited value for diagnosing ACS in patients with a normal or non-diagnostic ECG. Radiation of pain to the right arm increases the likelihood of ACS.

Biochemical and genetic variation in Mycoplasma fermentans strains from cell line, human and animal sources.

AIMS: To investigate the inter-strain variation in (i) substrate utilization and (ii) the restriction fragment length polymorphism (RFLP) pattern based on the distribution of an insertion element (IS1550) in Mycoplasma fermentans strains, and to establish any correlation between subgroups within the species and their source or habitat. METHODS AND RESULTS: Using a sensitive dynamic pH method, the pattern and kinetics of substrate utilization by a panel of 17 M. fermentans strains from various sources was determined. This study correlated the biochemical characteristics of these strains with RFLP patterns based on the distribution of an insertion sequence (IS1550) with the sources of the strains. The test isolates were divided into four major groups according to the pattern of substrates metabolized. Interestingly, two strains isolated from cell lines in RFLP cluster I failed to utilize arginine. Ovine strains showed distinct substrate utilization patterns and produced RFLP patterns not previously encountered. CONCLUSIONS: All strains utilized glucose, but the ability to utilize arginine, fructose and N-acetyl glucosamine varied. There was also some correlation evident between the metabolic data and the RFLP clusters. SIGNIFICANCE AND IMPACT OF THE STUDY: This study has provided a better understanding of the biochemical and genetic diversity of M. fermentans strains from various sources.

High inter-species and low intra-species variation in 16S-23S rDNA spacer sequences of pathogenic avian mycoplasmas offers potential use as a diagnostic tool.

In order to investigate its value for phylogenetic analysis, species characterisation and diagnosis, the 16S-23S rDNA intergenic spacer regions (ISRs) of the type strain of 23 avian Mycoplasma species were amplified and the sequences determined. Also sequenced were the reference strains of Mycoplasma iowae serotypes J, K, N, Q and R and a number of field strains of Mycoplasma synoviae, Mycoplasma gallisepticum, Mycoplasma meleagridis and M. iowae. The ISRs demonstrated a high level of size variation (178-2488bp) between species and did not include tRNA genes. Phylogenetic analysis performed using the information conflicted with that based on the 16S rDNA and was therefore not helpful for phylogenetic studies. However, the ISR did appear to be of value for determining species since there was high inter-species variation between all 23 avian Mycoplasma species, and in addition there was low intra-species variation, at least in the four pathogenic species. It could also be very useful as additional information in the description of a new species and as a target for species-specific PCRs.

Mycoplasma host specificity: fact or fiction?

Bacteria of the genus Mycoplasma are the smallest organisms known to be capable of self-replication. They only occur in association with animal host cells on which they are dependant for many pre-formed nutrients since they lack many of the metabolic pathways associated with energy production and the synthesis of cell components found in other species of bacteria. It is generally thought that most species of Mycoplasma are very host specific but there are many reports of mycoplasmas in hosts that are not perceived as their normal habitat. Sometimes these "crossings" may have a pathological impact particularly where there may be predisposing conditions such as immunodeficiency. These are often reported in humans but may also occur in animals whose immune or physiological status is not known. This review brings together some of these reported incidents and speculates on their potential impact for laboratory diagnosis.

Mycoplasma amphoriforme sp. nov., isolated from a patient with chronic bronchopneumonia.

A mycoplasma was isolated from the sputum of an immunodeficient patient with recurrent bronchitis. The isolate designated strain A39T was very fastidious and atypical for a mycoplasma in its colonial appearance. Classical biochemical tests for mycoplasma speciation could not differentiate the isolate from the pathogens Mycoplasma pneumoniae and Mycoplasma genitalium and serological identification as a recognized Mycoplasma species was lacking. Specific PCR detection for these two species was negative. Subsequently, other strains were isolated from human patients that appeared to be similar to strain A39T in their physiological and genetic characteristics. Analysis of the 16S rRNA gene placed strain A39T and other isolates in the pneumoniae group of mycoplasmas, with the highest sequence similarity to Mycoplasma testudinis (96.8 %), but with only 93.0 % similarity to M. pneumoniae and M. genitalium. Examination of the 16S-23S rRNA internally transcribed spacer sequence, protein electrophoresis profile, genome size and serological reactions indicated that this organism represents a novel species, for which the name Mycoplasma amphoriforme sp. nov. is proposed, with strain A39T (=NCTC 11740T=ATCC BAA-992T) as the type strain.

Retrospective observational case-control study comparing prehospital thrombolytic therapy for ST-elevation myocardial infarction with in-hospital thrombolytic therapy for patients from same area.

OBJECTIVES: To compare a system of prehospital thrombolytic therapy, delivered by paramedics under medical guidance, with in-hospital thrombolytic therapy in meeting National Service Framework (NSF) targets for treatment of acute myocardial infarction at a District General Hospital setting in England. DESIGN: Retrospective observational case-control study comparing patients with suspected acute myocardial infarction (AMI) treated with thrombolytic therapy in the prehospital environment with patients treated in hospital. SETTING: Wyre Forest District and Worcestershire Royal Hospital, UK. PARTICIPANTS: (A) All patients who received prehospital thrombolytic therapy for suspected AMI accompanied by electrocardiographic features considered diagnostic.(B) Patients who received thrombolytic therapy after arrival at hospital for the same indication, matched with group A by age, gender and postcode. MAIN OUTCOME MEASURES: 1. Call to needle time. 2. Percentage of patients treated within one hour of calling for medical help. 3. Appropriateness of thrombolytic therapy. 4. Safety of thrombolytic therapy RESULTS: 1. The median call to needle time for patients treated before arriving in hospital (n = 27) was 40 minutes with an inter-quartile range 25-112 (mean 43 minutes). Patients from the same area who were treated in hospital (n = 27) had a median time of 106 minutes with an inter-quartile range 50-285 (mean 126 minutes). This represents a median time saved by prehospital treatment of 66 minutes. 2. 60 minutes after medical contact, 96 % of patients treated before arrival in hospital had received thrombolytic therapy; this compares with 4% of patients from similar areas treated in hospital. 3. Myocardial infarction was confirmed in 92% (25/27) of patients who received prehospital thrombolytic therapy and similarly 92% (25/27) of those given in-hospital thrombolytic therapy. 4. No major bleeding occurred in either group. Group A suffered fewer in-hospital deaths than group B (1 versus 4). Cardiogenic shock (3 patients) and ventricular arrhythmia (5 patients) were seen only in group B. CONCLUSION: Paramedic-delivered thrombolytic therapy can be delivered appropriately, safely, and effectively. Time gains are substantial and can meet the national targets for early thrombolytic therapy in the majority of patients.

Routine chest radiography after permanent pacemaker implantation: is it necessary?

BACKGROUND AND AIMS: Chest radiographs (CXRs) are performed routinely after permanent pacemaker implantation to identify pacemaker lead position and exclude pneumothorax. We assessed the clinical value and need for this procedure. DESIGN: Retrospective analysis of pacemaker data and CXRs following permanent pacemaker insertion between December 2002 and February 2004. MATERIALS AND METHODS: Post-procedural CXRs were available in 125/126 consecutive patients after either first endocardial pacemaker implantation or insertion of at least one new lead. Subclavian vein puncture was used for venous access in all cases. CXRs were examined to establish the incidence of pneumothorax and assess pacing lead positions. The clinical records were examined in all patients who had subsequent CXRs or a further pacemaker procedure to identify the indication for these and to establish whether CXR had influenced patient management. RESULTS: In total, 192 post-procedural CXRs were performed, either postero-anterior (PA) and/or lateral views. Ventricular and/or atrial pacing lead contour and electrode position was considered radiographically appropriate in 86% CXRs. Fourteen per cent of post-procedural radiographs were considered to have radiologically sub-optimal pacemaker lead positioning. None of the patients with these "abnormal" radiographs experienced subsequent pacemaker complications or had further radiographs recorded at a later date. Later repeat CXRs were performed in 16 patients (13%) but only 3 patients (2%) had pacing abnormalities as the primary indication. All three had satisfactory pacing lead position on initial post-implantation and later radiographs, but required further procedures for lead re-positioning. Iatrogenic pneumothorax occurred in one patient (incidence 0.8%) in our series. CXR confirmed the clinical diagnosis and allowed an assessment of size to guide treatment. CONCLUSION: Routine CXR after permanent pacemaker insertion is not necessary in uncomplicated cases with adequate pacing characteristics.

Chronic bronchitis in immunocompromised patients: association with a novel Mycoplasma species.

Patients with primary antibody deficiency are prone to recurrent bronchitis, often caused by nonencapsulated Haemophilus influenzae and streptococcal infection. Productive cough often persists even after elimination of these organisms with antibiotics. During an investigation into the cause of unexplained chronic bronchitis in these patients, a novel Mycoplasma species (designated A39) was first isolated from the sputum of a man with X-linked agammaglobulinaemia. Screening of sputa from a further 45 patients with primary antibody deficiency showed that 10 were positive for a similar organism using culture and/or a polymerase chain reaction based on sequences within the 16S ribosomal RNA gene. A comparison of the sequence data showed that the organism was distinct from but similar to Mycoplasma pneumoniae and other closely related mycoplasmas found in humans and animals. Electron microscopy showed some unique morphological characteristics. Although respiratory symptoms improved after elimination of A39 from the sputum of the patient with X-linked agammaglobulinaemia, further work is needed to establish the organism as a pathogen.

Simple method for determining biovar and serovar types of Ureaplasma urealyticum clinical isolates using PCR-single-strand conformation polymorphism analysis.

Ureaplasma urealyticum has been associated with urethritis in men, obstetric problems in women, and respiratory distress syndrome in preterm infants. U. urealyticum can be divided into two biovars comprising 14 serovars. Partial sequences of genes encoding the multiple-banded antigens of the cell surface are known. Using a commercially available precast DNA mutation detection gel system, we have developed a simple and reproducible PCR-single-strand conformation polymorphism analysis method for differentiating the biovars of this species that reveals five patterns among the 14 serovars and enables clinical isolates to be typed directly from broth cultures.

Distribution of ecto 5'-nucleotidase on Mycoplasma species associated with arthritis.

The enzyme ecto 5'-nucleotidase (5'N) was found to be active on 8/14 strains of Mycoplasma fermentans, K(m) (+/-S.D.) 3.8+/-2.8 microM 5'-AMP, and on the type strain of Mycoplasma pulmonis, K(m) 0.63 microM 5'-AMP. The six M. fermentans strains lacking 5'N activity were related by restriction fragment length polymorphism typing. At pH 8.5, the type strains of Mycoplasma arthritidis, Mycoplasma buccale and Ureaplasma urealyticum showed a relatively non-specific phosphatase activity against 5'-AMP but no activity was shown by the type strains of Mycoplasma genitalium, Mycoplasma hominis, Mycoplasma orale, Mycoplasma penetrans, Mycoplasma pneumoniae and Mycoplasma salivarium at this pH. M. fermentans has been reported from rheumatoid joints, which show a raised 5'N activity on their synovial cells and in their fluid which may be associated directly or indirectly with the mycoplasma.

'Candidatus Odyssella thessalonicensis' gen. nov., sp. nov., an obligate intracellular parasite of Acanthamoeba species.

An intracellular bacterium, strain L13, was observed infecting an environmental isolate of an Acanthamoeba species. The bacterium could not be recovered on axenic medium but was recovered and cultivated in vitro using cultures of Acanthamoeba polyphaga. The 16S rRNA gene sequence of L13 was found to be new, sharing less than 84% similarity with other sequences in the GenBank/EMBL database. L13 was found to be a member of the alpha-Proteobacteria, sharing an evolutionary line of descent with a group of uniquely obligate intracellular organisms comprised of Caedibacter and Holospora species and the NHP bacterium. Viable bacteria appeared to be highly motile within amoebae. Ultrastructural analysis of the bacterium demonstrated that it is rod-shaped and possesses a typical Gram-negative cell wall, but has no other outstanding features except small vesicle-like structures often associated with the outer surface of each bacterium. The host range of L13 was found to be limited to the genus Acanthamoeba. In A. polyphaga, L13 infection was slow to manifest when cultures were incubated below 30 degrees C, but at higher temperatures bacteria multiplied prolifically and induced host cell lysis. The protein profile of the bacterium purified from the amoebae was assessed by SDS-PAGE and its G+C content was estimated to be 41 mol%. Although these results support the proposal of L13 as a new species, its obligate intracellular nature prevented isolation of a definitive type strain. L13 is therefore proposed as 'Candidatus Odyssella thessalonicensis' gen. nov., sp. nov.

Laparoscopically assisted colon resection for colon carcinoma: perioperative results and long-term outcome.

BACKGROUND: The role of laparoscopic colon resection in the management of colon cancer is unclear. The aims of this study were to compare perioperative results and long-term outcomes in patients randomized to either open (O) or laparoscopically assisted (LA) colon resection for colon cancer. METHODS: A prospective randomized trial comparing O to LA colon resection was conducted from January 1993 to November 1995. Preoperative workup, intraoperative results, complications, length of stay, pathologic findings, and long-term outcomes were compared between the two groups. Statistical analysis was performed with t-test. Follow-up periods ranged from 3.5 to 6.3 years (mean, 4.9 years). RESULTS: No port-site or abdominal wall recurrences were noted in any patients. [table: see text] CONCLUSIONS: These results suggest that laparoscopically assisted colon resection for malignant disease can be performed safely, with morbidity, mortality, and en bloc resections comparable with those of open laparotomy. Long-term (5-year) follow-up assessment shows similar outcomes in both groups of patients, demonstrating definite perioperative advantages with LA surgery and no perioperative or long-term disadvantages.

Ogilvie's syndrome in the surgical patient: a new therapeutic modality.

Acute colonic pseudo-obstruction, Ogilvie's syndrome, most often appears as a complication of other clinical conditions. It is characterized by massive colonic dilation in the absence of a mechanical cause. Therapy for this condition has traditionally been colonoscopic decompression via a flexible colonoscope. We performed a retrospective study to assess the efficacy of Cystografin enema for colonic decompression in Ogilvie's syndrome. We present a series of 18 patients who developed Ogilvie's syndrome while hospitalized for trauma (n = 10), burn (n = 1), gastrointestinal surgery (n = 4), and hip replacement (n = 3). The mean pre-enema cecal size was 13 cm (range 10 to 15 cm). The mean postenema cecal size was 8.5 cm (range 6 to 15 cm). Fifteen of the 18 patients underwent Cystografin enema as the primary mode of decompression. Three had undergone prior colonoscopy, which had failed. One of the 18 patients required repeat enema for inadequate decompression after the first enema and one underwent colonoscopy for recurrence. Two patients underwent operative intervention after the enema. There were no complications related to the enema. In all patients we were able to rule out a mechanical cause of large bowel obstruction. We believe the safety, efficacy, and ease of this procedure make Cystografin enema optimal first-line treatment for acute colonic pseudo-obstruction.

Differential effects of heparin on the early and late phases of hepatic ischemia and reperfusion injury in the pig.

The mechanisms by which heparin protects the liver during induced episodes of liver ischemia-reperfusion are poorly understood. Previous work in a swine model demonstrated that serum levels of glycohydrolases and lipid peroxide peaked within 3 h after 45 minutes of hepatic ischemia followed by reperfusion. Serum levels of lactate dehydrogenase and aspartate aminotransferase peaked 20-24 h later. The aim of this study was to evaluate the effect of heparin on these two-phases of enzyme release, using a pig model of hepatic ischemia-reperfusion injury. Twenty male swine were divided into control (n = 8) and heparin (n = 12) groups. In the heparin group, heparin was administered prior to and concurrent with ischemia-reperfusion. Following 45 min of hepatic ischemia, the levels of beta-galactosidase, beta-glucosidase, acid phosphatase, purine nucleoside phosphorylase, lipid peroxides, lactate dehydrogenase, and aspartate aminotransferase in serum were monitored for up to 166 h and compared to pre-ischemic and control levels. With heparin infusion, the peak levels of beta-galactosidase, beta-glucosidase, and the lipid peroxide were reduced to 50-60% of the control levels. Acid phosphatase and purine nucleoside phosphorylase activities in serum were reduced to 25% and 60%, respectively. The peak concentrations of lactate dehydrogenase and aspartate aminotransferase were reduced to about 25% of the control level. In addition, the serum enzymes of control pigs did not return to pre-ischemic levels until 2 weeks after hepatic ischemia, while they normalized in less than 1 week in the heparin-treated animals. Systemic heparinization had different protective effects on the first and secondary phases of liver injury. These differences may reflect heparin protection of different types of liver cells. The protection of the parenchymal cells may be the combined result of reduced sinusoidal cell injury and the anticoagulant properties of heparin.