Management of a patient with an unexpected obstructing carinal mass

Surgical procedures involving the airway or for mediastinal masses present considerable challenges for the anesthesiologist. Aside from the obvious technical challenges of providing ventilation, the anesthesiologist must share the airway with the surgeon. Careful and meticulous preoperative evaluation and preparation and intraoperative interaction with the surgical team is critical to assure control of the airway. We report a case of management of a patient with an unexpected near total obstruction of the airway from a carinal mass.

A molecular basis for heterosis

Alcohol dehydrogenase allodimers composed of an unstable active subunit and a stable but inactive subunit are both active and stable. The implication of this finding for the problem of heterosis is discussed.

Molecular analysis of ds controlling element mutations at the adh1 locus of maize

An active maize Adhl-F gene, a Ds-induced mutant of this gene, and two independent Ac-induced revertant alleles have been isolated. The Ds mutant differs from the progenitor allele in having a 405-base pair insertion flanked by a direct repeat of 8 bp. The repeat is a duplication of the 8 bp existing at the point of insertion in the 5' untranslated region of the gene. The insertion sequence is AT-rich (A, adenine; T, thymine) and has 11-bp inverted repeat sequences at its termini. In the revertants the insertion with its inverted repeats is deleted, but the 8-bp direct repeats remain in modified form. These results establish that the 405-bp sequence is a Ds element. The Adh1 messenger RNA level is low in the Ds mutant, and it appears that new sites for transcription initiation or RNA processing or both are used. There are at least 30 sequences in the maize genome related to the Ds element.

Gene-controlled cytosine demethylation in the promoter region of the Ac transposable element in maize

The transposase product of the Ac transposable element causes demethylation of the BamHI site in the promoter region of Ac. This site remains methylated in Ds9, the deletional derivative of Ac that fails to make an active transposase. In the presence of an active Ac element the BamHI site of Ds9 is demethylated. Transcription of the element is correlated with the demethylation of the promoter region. Evidence is presented that supports the model that the trans-acting protein causes site-specific demethylation by inducing a configuration change in chromatin structure making the site inaccessible to the methylase. A chromosome alteration that involves the insertion of the 4.5-kilobase Ac element results in the methylation of Pvu I target sites about 1 kilobase removed from the point of insertion.

Tissue-specific regulation of gene function: Presetting and erasure

Evidence is presented for presetting and erasure at the P locus of maize. The presence of an Mp transposable controlling element in the P(vv) allele affects the presetting and thus the regulation of gene function in different tissues.

A pollen selection system for alcohol-dehydrogenase-negative mutants in plants

Exposure of freshly shed maize pollen to allyl alcohol vapors allows selective fertilization by mutant alcohol-dehydrogenase-negative grains. Wild-type pollen grains are killed by the enzymatic conversion of allyl alcohol to the highly toxic acrylaldehyde.

High prevalence of non-productive FeLV infection in necropsied cats and significant association with pathological findings

Applying a combination of semi-nested PCR and immunohistology (IHC), the presence of exogenous feline leukemia virus infection was studied in 302 necropsied cats with various disorders. 9% showed the classical outcome of persistent productive FeLV infection which was represented by FeLV antigen expression in different organs. 152 cats (50%) harboured exogenous FeLV-specific proviral sequences in the bone marrow but did not express viral antigen. These cats were considered as horizontally but non-productively infected.

Statistical evaluation showed a significant association of non-productive horizontal FeLV infection with a variety of parameters. Non-productively infected cats were statistically significantly older and more often originated from animal shelters than cats without exogenous FeLV infection. Furthermore, some pathological disorders like anemia, panleukopenia, and purulent inflammation showed significant association with non-productive FeLV infection. No significant association was found with lymphosarcoma, known for a long time to be induced by productive FeLV infection.

A single, improvised "Kassam" rocket explosion can cause a mass casualty incident: a potential threat for future international terrorism?

INTRODUCTION

Over 2000 improvised rockets (called "Kassam" rockets) have been targeted at the south of Israel from the Gaza strip since 2001. Most of them have injured relatively few people. The first known case of a multicasualty incident (MCI) caused by the landing of a single, improvised rocket is described.

METHODS

The event is described according to the disastrous incidents systematic analysis through components, interactions and results methodology (DISAST-CIR).

RESULTS

The rocket hit a military training tent camp in the south of Israel at 01:18 hours. At that time, all soldiers were in bed and were not using any protective gear. A total of 76 soldiers was injured (three severe, eight moderate and 65 mild). The most prevalent types of injuries were upper extremity (33%) and lower extremity (30%) trauma, tinnitus (30%) and acute stress reactions (32%). A total of 67 casualties was evacuated to the nearest level two hospital, Barzilai, in a two-phase distribution characterised by different patterns of injury severity and type. All urgent casualties arrived at hospitals within 1 h 24 minutes, whereas most stress casualties arrived in the later phase. Seven casualties were secondarily transported to level one trauma centres. 42 of the casualties were hospitalised and 17 needed urgent surgery. None has died.

CONCLUSIONS

A single low-tech mortar with poor accuracy and small warhead (estimated weight of 10 kg only) can cause a large-scale MCI. As international terrorist organisations can easily gain access to improvised rockets, the latter may become a threat in many countries. Emergency systems should thus be prepared for that adverse possibility.

New evidence for the role of TNF-alpha in liver ischaemic/reperfusion injury

BACKGROUND

Tumour necrosis factor-alpha (TNF-alpha) plays a key role in causing ischaemia/reperfusion (I/R) injury. I/R also causes activation of xanthine oxidase and dehydrogenase (XDH + XO) system that, via generated free radicals, causes organ damage. We investigated the effect of ischaemia, reperfusion and non-ischaemic prolonged perfusion (NIP) on TNF-alpha and XDH + XO production in an isolated perfused rat liver model.

MATERIALS AND METHODS

Rat livers underwent 150 min NIP (control group) or two hours of ischaemia followed by reperfusion (I/R group). TNF-alpha (TNF-alpha mRNA and protein level), XDH + XO production and bile secretion were determined in tissue and effluent at baseline, at 120 min of ischaemia, after 30 min of reperfusion (I/R group) and after 120 and 150 min of prolonged perfusion (control).

RESULTS

Unexpectedly, neither ischaemia nor reperfusion had any effect on TNF-alpha production. TNF-alpha in effluent was 11 +/- 4.8 pg mL(-1) at baseline, 7 +/- 3.2 pg mL(-1) at the end of ischaemia, and 13 +/- 5.3 pg mL(-1) after 30 min of reperfusion. NIP, however, caused a significant increase of TNF-alpha synthesis and release. TNF-alpha effluent level after 120 and 150 min of perfusion was 392 +/- 78.7 pg mL(-1) and 408 +/- 64.3 pg mL(-1), respectively. TNF-alpha mRNA in tissue was also significantly elevated compared to baseline levels (1.31 +/- 0.2 P < 0.001 and 1.38 P < 0.002, respectively). Decrease of liver function (expressed by bile secretion) during I/R and NIP was accompanied by significant XDH + XO elevation.

CONCLUSION

This is the first evidence that NIP, and not I/R, is the decisive trigger for TNF-alpha production. This study leads to a better understanding of pathogenesis of liver I/R and perfusion damage.

Three thioesterases are involved in the biosynthesis of phosphinothricin tripeptide in Streptomyces viridochromogenes Tü494

Phosphinothricin tripeptide (PTT) is a peptide antibiotic produced by Streptomyces viridochromogenes Tü494, and it is synthesized by nonribosomal peptide synthetases. The PTT biosynthetic gene cluster contains three peptide synthetase genes: phsA, phsB, and phsC. Each of these peptide synthetases comprises only one module. In neither PhsB nor PhsC is a typical C-terminal thioesterase domain present. In contrast, a single thioesterase GXSXG motif has been identified in the N terminus of the first peptide synthetase, PhsA. In addition, two external thioesterase genes, theA and theB, are located within the PTT biosynthetic gene cluster. To analyze the thioesterase function as well as the assembly of the peptide synthetases within PTT biosynthesis, several mutants were generated and analyzed. A phsA deletion mutant (MphsA) was complemented with two different phsA constructs that were carrying mutations in the thioesterase motif. In one construct, the thioesterase motif comprising 45 amino acids of phsA were deleted. In the second construct, the conserved serine residue of the GXSXG motif was replaced by an alanine. In both cases, the complementation of MphsA did not restore PTT biosynthesis, revealing that the thioesterase motif in the N terminus of PhsA is required for PTT production. In contrast, TheA and TheB might have editing functions, as an interruption of the theA and theB genes led to reduced PTT production, whereas an overexpression of both genes in the wild type enhanced the PTT yield. The presence of an active single thioesterase motif in the N terminus of PhsA points to a novel mechanism of product release.

Risk factors for the development of cephalic arch stenosis

PURPOSE

The creation of a vascular access is necessary in hemodialysis patients, including those with marginal vessels. Upper arm fistulae are attractive due to the ease of creation and of achieving high access flow rates. Cephalic arch stenosis (CAS) can lead to failure of upper arm fistulae and is increasingly identified. We hypothesized that CAS is promoted by high blood flow rates, brachiocephalic fistulae, and an angle of cephalic vein insertion approaching 90 degrees.

METHODS

All patients requiring a fistulogram between January 2004 and May 2006 had surveillance fluoroscopy of the central veins. Demographic, clinical and laboratory parameters were collected and the angle of the cephalic vein insertion measured by 3 blinded independent observers.

RESULTS

Fifty-eight patients had fistulograms and CAS was detected in 18 subjects. Significant differences between the CAS and non-CAS groups were brachiocephalic fistula site (p = 0.046), access flow (mL/min) (p = 0.012), and absence of diabetes (p = 0.03). Univariate predictors of CAS include access flow (per 100 mL/min) (p = 0.042), platelet count (p = 0.031) and calcium-phosphate product (p = 0.026). The relationship of brachiocephalic site and CAS was confounded by access flow [(per 100 mL/min)*brachiocephalic fistula site (p = 0.016)] and fistula age [brachiocephalic fistula site*fistula age (p = 0.017)]. In multivariate analysis, renovascular disease, calcium-phosphate product, platelet count and access flow (per 100 mL/min)*brachiocephalic fistula predicted CAS (p < 0.001, Negelkerke's R-Square = 0.55). The angle of insertion of the cephalic vein was not predictive for CAS.

CONCLUSIONS

CAS may be a long-term consequence of high blood flow rates. The interaction of access flow and brachiocephalic fistula supports the hypothesis that high flow through a brachiocephalic fistula promotes CAS. The multiple factors influencing cephalic arch remodeling require further research.

Sequencing and analysis of the biosynthetic gene cluster of the lipopeptide antibiotic Friulimicin in Actinoplanes friuliensis

Actinoplanes friuliensis produces the lipopeptide antibiotic friulimicin, which is a cyclic peptide with one exocyclic amino acid linked to a branched-chain fatty acid acyl residue. The structural relationship to daptomycin and the excellent antibacterial performance of friulimicin make the antibiotic an attractive drug candidate. The complete friulimicin biosynthetic gene cluster of 24 open reading frames from A. friuliensis was sequenced and analyzed. In addition to genes for regulation, self-resistance, and transport, the cluster contains genes encoding peptide synthetases, proteins involved in the synthesis and linkage of the fatty acid component of the antibiotic, and proteins involved in the synthesis of the nonproteinogenic amino acids pipecolinic acid, methylaspartic acid, and 2,3-diaminobutyric acid. By using heterologous gene expression in Escherichia coli, we provide biochemical evidence for the stereoselective synthesis of L-pipecolinic acid by the deduced protein of the lysine cyclodeaminase gene pip. Furthermore, we show the involvement of the dabA and dabB genes in the biosynthesis of 2,3-diaminobutyric acid by gene inactivation and subsequent feeding experiments.

The possible significance of Clostridium spp. in blood cultures

The significance of Clostridium spp. in blood cultures was evaluated by two methods. In the first part of the study, a group of 80 patients with Clostridium spp. bacteraemia was compared with a group of 100 patients with Bacillus spp. in blood cultures, making the assumption that Bacillus almost invariably represents contamination (pseudobacteraemia). Significant differences were found between the two groups, suggesting that growth of Clostridium did not represent pseudobacteraemia. Patients with Clostridium bacteraemia were older, had a higher frequency of gastrointestinal disease (especially colorectal tumours), were associated more frequently with polymicrobial bacteraemia, and had a higher mortality rate. In the second part of the study, each of the 80 cases of Clostridium bacteraemia was evaluated individually for clinical relevance by an infectious diseases expert. In two-thirds of the cases, isolates of Clostridium from blood were considered to be of clinical relevance, whereas in one-third of cases, the clinical significance of this finding was doubtful. It was concluded that growth of Clostridium spp. in blood cultures, even in the absence of one of the histotoxic syndromes, is often of clinical significance, and that such findings should be properly evaluated and not ignored.

“All-in-one-plate” E-test and disk diffusion susceptibility co-testing for multiresistant Acinetobacter baumannii

Multiresistant Acinetobacter baumannii requires ancillary manual susceptibility testing with the E-test and disk diffusion when tested with the VITEK-2 system (bioMérieux, Marcy l'Etoile, France). In the study presented here, the E-test and disk diffusion were combined in a single plate, and the method was verified by comparing categorical agreement of combined and control plates. There were no very major, major or minor errors, and similar results were obtained for all ten representative bacterial strains used as controls. Co-testing is thus feasible, accurate and reproducible, and it merits evaluation with other bacterial species.