Metallothionein-IIA promotes initial neurite elongation and postinjury reactive neurite growth and facilitates healing after focal cortical brain injury

Metallothioneins (MTs) are small, cysteine-rich, metal binding proteins. Their function has often been considered as stress-related proteins capable of protecting cells from heavy metal toxicity and oxidative free radicals. However, recent interest has focused on the brain-specific MT-III isoform, which has neurite-inhibitory properties. To investigate the effect of another MT isoform, human MT-IIA, on neurite growth, we used rat cortical neuron cultures. MT-IIA promoted a significant increase in the rate of initial neurite elongation of individually plated neurons. We also investigated the effect of MT-IIA on the neuronal response to axonal transection in vitro. MT-IIA promoted reactive axonal growth after injury, and, by 18 hr after transection, MT-IIA had promoted axonal growth across the injury tract. Exogenous application of MT-IIA after cortical brain injury promoted wound healing, as observed by a significant decrease in cellular degradation at 4 d after injury. Furthermore, MT-IIA-treated rats exhibited numerous SMI-312-immunoreactive axonal processes within the injury tract. This was in contrast to vehicle-treated animals, in which few axonal sprouts were observed. By 7 d after injury, MT-IIA treatment resulted in a total closing over of the injury tract by microglia, astrocytes, and reactive axonal processes. However, although some reactive axonal processes were observed within the injury tract of vehicle-treated rats, the tract itself was almost never entirely enclosed. These results are discussed in relation to a possible physiological role of metallothioneins in the brain, as well as in a therapeutic context.

The decline of training in open biliary surgery: effect on the residents' attitude toward bile duct surgery

BACKGROUND

After more than a decade of growth for laparoscopic cholecystectomy and decline in open cholecystectomy, the impact on the training of resident's in other open biliary operations can be analyzed quantitatively.

METHODS

The national operative statistics for residents' operations from 1988 to 2001 (data in the public domain) were analyzed by regression analysis to establish trends and to calculate the rate of change. For laparoscopic biliary operations, the changes in laparoscopic and open operations over time and the number of operations per trainee each year were used to measure the growth of a laparoscopic operation and to predict future trends. A survey of attitude, management algorithm, and self-confidence for coping with unexpected events in laparoscopic cholecystectomy also was conducted for senior residents and recent graduates.

RESULTS

In 2001, open cholecystectomy decreased to 28%, open common duct exploration to 27%, sphincteroplasty to 20%, of 1988 (baseline year) levels. Cholecystostomy and choledochoenteric bypass decreased to 70% and 75%, respectively. The decline began before the era of laparoscopic cholecystectomy, but accelerated after its introduction. Many of the recent graduates surveyed in one program indicated a preference for a nonsurgical, mainly endoscopic, approach for all bile duct conditions, but also for the assistance of senior surgeons in the operative management of unexpected events.

CONCLUSION

The popularity of noninvasive therapy in biliary surgery significantly reduced the resident's exposure to open biliary surgery, adversely affecting their confidence in the management of unexpected events encountered during laparoscopic operations. Supplemental and remedial education measures must be instituted in training programs.

Metallothionein-III inhibits initial neurite formation in developing neurons as well as postinjury, regenerative neurite sprouting

Human metallothionein-III (MT-III) is an inhibitory factor deficient in the Alzheimer's disease (AD) brain. MT-III has been identified as an inhibitor of neurite sprouting, and its deficiency has been proposed to be involved in the formation of neurofibrillary tangles (NFT) in the neuropathology of AD. However, there has been limited investigation of the proposed neurite growth inhibitory properties of MT-III. We have applied recombinant human MT-III to both single cell embryonic cortical neurons (to investigate initial neurite formation), as well as mature (21 days postplating) clusters of cortical neurons (to investigate the regenerative sprouting response following injury). We report that MT-III inhibited the initial formation of neurites by rat embryonic (E18) cortical neurons. This was based on both the percentage of neurite positive neurons and the number of neurites per neuron (45 and 30% inhibition, respectively). Neurite inhibition was only observed in the presence of adult rat brain extract, and was also reversible following replacement of MT-III-containing medium. MT-III inhibited the formation and growth of both axons and dendrites. Of more physiological significance, MT-III also inhibited the regenerative neurite sprouting response following axonal transection. The morphology of sprouting neurites was also altered, with the distal tip often ending in bulb-like structures. Based on these results, we propose that MT-III, in the presence of brain extract, is a potent inhibitor of neurite sprouting, and may be involved in abnormal sprouting potentially underlying both AD and epilepsy.

Sheep have an unusual variant of the brain-specific metallothionein, metallothionein-III

Sheep metallothionein-III (MT-III) cDNA was isolated from a brain cDNA library and characterized. In contrast with MT-III from other species, sheep MT-III cDNA is predicted to encode a protein with significantly different metal-binding properties, owing to the loss of three of its cysteine residues. RT-PCR from other sheep confirmed that this aberrant structure is ubiquitous in this species. MT-III was successfully isolated from sheep brain, demonstrating that the cDNA does give rise to a protein product of the predicted structure. Sheep MT-III is similar to other mammalian MT-IIIs in that it retains the Cys-Pro-Cys-Pro motif which is thought to encode growth-inhibitory activity, and we show that it is likewise able to inhibit neuron survival in vitro. This is the first naturally occurring variant of MT-III (or any other major mammalian MT gene) which gives rise to a protein product. These findings are discussed in light of proposed roles of MT in the mammalian brain.

Influenza vaccination, hospitalizations, and costs among members of a Medicare managed care plan

OBJECTIVE

To evaluate the effectiveness and possible cost savings of influenza vaccination.

SUBJECTS

Members age 65 and older in a Medicare managed care plan during the 1994-1995, 1995-1996, and 1996-1997 influenza seasons.

RESEARCH DESIGN

The study examined administrative data on influenza vaccination and subsequent hospitalizations. Outcomes included hospitalization with pneumonia or influenza, with any respiratory condition, and with congestive heart failure (CHF).

RESULTS

Vaccinated subjects experienced fewer hospitalizations with respiratory conditions or CHF than had unvaccinated subjects (OR=0.8 (95% CI, 0.7, 0.9) in analyses adjusted for age, sex, pneumococcal vaccination, health utilization, and morbidity). Analyses adjusted in addition for ethnicity obtained similar results among the subgroup of members whose ethnicity was known. Subjects without major disease in the previous 12 months had lower odds ratios for vaccination than subjects with major disease (OR values of 0.5 [95% CI, 0.4, 0.7] and 0.9 [95% CI, 0.8, 1.1], respectively). Subjects ages 65 to 79 had lower odds ratios for vaccination than subjects ages 80 and older (OR values of 0.7 [95% CI, 0.6, 0.9] and 0.9 [95% CI, 0.8, 1.1], respectively). Estimated cost savings averaged about $80 per vaccinated subject.

CONCLUSIONS

Subjects ages 65 to 79 who had received influenza vaccination experienced fewer hospitalizations and had lower costs than had unvaccinated subjects. Associations were weaker for subjects age 80 and older. The results, consistent with recommendations for the use of influenza vaccine, suggest that people ages 65 to 79 should be heavily targeted for vaccination.

Carbon dioxide flux density in cultivated rice paddy field

The carbon dioxide flux density in a subtropical cultivated rice paddy field were determined over four crop seasons (two consecutive years) at five stages of rice plant development, transplanting, active tillering, booting, flowering and ripening, and an idle period between crops. During 24 h sampling periods at those stages, the CO2 flux densities were measured and found to be -2,000 to 55,000 mg CO2/m2/day in the first year and 600 to 29,000 mg CO2/m2/day in the second year in acrylic chambers covering rice plants. The CO2 flux densities in glass domes without plants but with soil were -700 to 6,000 mg CO2/m2/day in the first year and 147 to 4,500 mg CO2/m2/day in the second year. The data for the CO2 flux density over an entire year are extrapolated. Although our non-controlled environment experiments have inherent drawbacks, the collected data indicate that continuous rice cultivation has a tendency to result in increased CO2 emissions.

The clinical diagnosis of chronic acalculous cholecystitis

BACKGROUND

Chronic acalculous cholecystitis (CAC), a diagnosis of exclusion, appears to be more common than was previously thought. We correlated the pathology with test results and response to treatment in a prospective study to obtain data for evidence-based management.

METHODS

The study subjects were patients with chronic biliary symptoms but had normal sonogram results. They were further investigated with esophagogastroduodenoscopy, multidiscipline evaluations, and cholecystokinin-stimulated scintigraphy (CCK-HIDA). They were offered laparoscopic cholecystectomy (LC) when the symptoms were intransigent, and the main abnormality was a low ejection fraction (EF) as determined by CCK-HIDA. We analyzed the histologic findings of the gallbladder, CCK-HIDA EF, and clinical outcomes during the control period with a concurrent series of LC for calculus from the same surgeons.

RESULTS

Of 176 cholecystectomies for biliary pain without stones, 152 had pathologically verified CAC. EF by CCK-HIDA was low in patients with CAC (18%) and low in normal gallbladders (26%). In the same period, 497 patients had cholecystectomies for cholelithiasis. Lasting symptom relief for CAC after LC was not different from that for calculous disease (85% vs 90%).

CONCLUSIONS

The syndrome consisting of chronic biliary symptoms, stone-free sonograms, low EF in CCK-HIDA, and absence of other pain sources is highly predictive for CAC, which is well treated with LC, with results similar to those for calculous disease.

Correlating physical and mental health status with satisfaction in a health plan

Managed care organizations strive to prevent illness where possible and improve patient outcomes for enrollees. The objective of this study was to examine how data from the Medical Outcomes Study Short Form-12 from more than 45,000 health plan enrollees can be used to: compare enrollee health status with national norms, examine the relationship between health status and member characteristics, and determine the extent to which health status is related to member satisfaction. The member survey measured physical and mental health and the following aspects of satisfaction: access, communication, and medical services. The researchers found that physical and mental health status were significantly associated with age, education, and ethnicity, whereas satisfaction was positively correlated with mental health status. Monitoring the health status of enrollees through the administration of a short, well-validated questionnaire can provide useful information in comparison with national norms as well as important insights regarding potential areas to target for quality improvement initiatives.

Pretarsal fat compartment in the lower eyelid

It is generally accepted that there are three infraorbital fat regions in the lower eyelid; medial, central, and lateral compartments. However, removing only the fat in the lateral compartment does not remove the bulge just below the eyelashes, which is caused by another fat pad. The aim of this study was to describe the anatomy of the pretarsal fat compartment and to demonstrate its clinical implications in lower lid blepharoplasty. Ten cadavers (total 20 lower eyelids) were studied. A skin-muscle flap was reflected to expose the soft pretarsal structures. A small stab incision was made on the lateral portion of the sac containing fat on the tarsus. Methylene blue dye was injected into the sac. Specimens were fixed and sagittal sections in four different planes were prepared for histological analysis. The injected dye remained within the sac and demarcated it as a pear or cone shaped structure. This encapsulated fat compartment sits on the lateral half of the tarsal plate above the lateral compartment fat. Auxillary or submuscular fat is well known. This study, however, designates the pretarsal fat as "encapsulated" in a compartment instead of being unbound. We have named it the "pretarsal fat compartment." Histologically, orbital septal fibers separate "pretarsal fat" from lateral infraorbital fat. It is recommended that fat in the pretarsal fat compartment be removed during lower lid blepharoplasty in order to alleviate the bulge or knoll of the skin just below the lower eyelashes.

Histomorphometry of parietal bones versus age and race

Surgeons are used to obtaining bone grafts of calvaria, which are abundant and available. The outer table of the parietal bone can be split, usually at the level of the diploic interstice, with an osteotome. Inadvertently violating the inner table and the dura leads some surgeons to avoid using the outer table in the elderly. Sullivan and Smith measured the thickness of the outer tables, diploe, and inner table of 37 cadavers (average age, 59 years) and found each layer to be well preserved distinctly. However, they suggested that calvaria become brittle in patients older than 50 years of age. The current authors hypothesized that diploic composition is not changed, even in the elderly. The thickest part of the parietal bone of 49 Koreans and 30 whites were acquired, and undecalcified slides were made. Via light microscopy, using the National Institutes of Health image, the following measurements were made: the thickness of the parietal bone (PT), outer table (OT), diploe (DT), and inner table (IT); trabecular bone volume percent (TBV); trabecular thickness (TT); and trabecular separation (TS). There was no significant difference in the thickness of the OT, DT, and IT of the PT, TBV, TT, and TS among different ages. The PTs of women were thicker than men's. The PTs of whites were significantly thicker than Koreans'. This study disclosed that the DT is not different among varying age groups and is not sclerosed in the persons older than 80 years, and the OT of these individuals is not brittle. Thus, surgeons do not need to hesitate when taking the OT of the PT in older patients. However, the selection of the site is attentive to PT. The thickest posteromedial part of the PT is favorable and safe as a donor.

Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs

BACKGROUND

Despite randomized controlled trials, the merits of laparoscopic hernia repair remain poorly defined. A meta-analysis may provide a timely overview.

METHODS

An electronic MEDLINE search, supplemented by a manual search, yielded 14 randomized controlled trials with usable statistical data, involving 2,471 patients. The trials were grouped for separate meta-analyses according to the control operation, either a tension-free or sutured repair, used for comparison. The effect sizes for operating time, postoperative pain, return to normal activity, and early recurrence were calculated, using a random-effects model when the effect sizes were heterogeneous and without subcategories.

RESULTS

In all meta-analyses, the laparoscopic operation was significantly longer. When compared with tension-free repairs, the laparoscopic operation showed no advantage in terms of postoperative pain, but resulted in a shorter recovery (marginal significance). As compared with sutured repair, both postoperative pain and recovery were in favor of the laparoscopic operation. When all 14 trials were analyzed together, laparoscopic repairs still had moderately reduced postoperative pain and recovery time.

CONCLUSIONS

Laparoscopic hernia repair has a modest advantage over conventional repairs. This advantage is more apparent when laparoscopic repairs are compared with sutured repairs rather than tension-free repairs.

Impact of a dedicated trauma service on the quality and cost of care provided to injured patients at an urban teaching hospital

BACKGROUND

To determine the impact of a dedicated trauma service on cost and quality of care in an urban teaching hospital, a before-and-after study was designed. The key elements of the trauma service were dedicated in-house trauma attending surgeons and residents, and continuity and integration of trauma care.

METHODS

Injury Severity Scores and probabilities of survival for each patient were calculated from the hospital International Classification of Diseases, Ninth Revision, codes, and individual patient costs were estimated from charges using the Medicare Cost Report.

RESULTS

The trauma service resulted in a significant increase in the severity of injuries. There was a highly significant (p<0.001) increase in the mean probability of death (from 0.16 to 0.21). There was no change in actual mortality. Although the mean cost of care increased by 16.6%, there were small reductions in the cost of care of the most severely injured patients.

CONCLUSION

A dedicated trauma service has a positive impact on the quality of care.

A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy

BACKGROUND

Despite many randomized controlled trials, the merits of laparoscopic appendectomy remain unclear. A meta-analysis may provide insights not evident from any individual studies.

DATA SOURCES

Systematic literature search yielded 17 trials (1,962 subjects) of true randomized design with usable statistical data comparing laparoscopic and conventional appendectomy in adults. The effect sizes for operating time, hospitalization, postoperative pain, return to normal activity, wound infection, and intra-abdominal abscess were calculated, using the random effects model to allow for heterogeneity. An estimate of the robustness of all positive findings was also calculated.

RESULTS

Modest but statistically significant effect sizes were found for four of the six outcome measures. Laparoscopic appendectomy takes 31% longer to perform, but results in less postoperative pain, faster recovery (by 35%), and lower wound infection rates (by 60%).

CONCLUSION

Laparoscopic appendectomy offers significant improvement in postoperative outcomes at the cost of a longer operation.

An anatomical study of the junction of the orbital septum and the levator aponeurosis in Orientals

The anatomical relationships of the orbital septum and levator aponeurosis has been studied in 40 eyelids subjected to blepharoplasty and corrective ptosis surgery by dissection in 10 cadavers and in histological sections. The orbital septum originates from the arcus marginalis of the frontal bone and consists of two layers. The whitish outer (superficial) layer, containing vertically running vessels, descends just inside the orbicularis oculi muscle to interdigitate with the levator aponeurosis with loose connective tissue, then disperses inferiorly. The inner (deep) layer follows the superficial one initially, then reflects at the levator aponeurosis and continues posteriorly with the levator sheath. We reconfirmed Whitnall's original description that the levator sheath thickens to form the superior transverse ligament runs continuously inferiorly anterior to the levator aponeurosis and forms the inner layer of the orbital septum. This detailed anatomical analysis should assist in performing upper eyelid surgery such as the Oriental double fold operation or levator resection.

Unsuspected choledocholithiasis first diagnosed at laparoscopic cholecystectomy: treatment by trans-cystic duct stenting and elective stent-guided sphincterotomy

BACKGROUND

Despite advances in laparoscopic surgery, management of unsuspected choledocholithiasis diagnosed at laparoscopic cholecystectomy is controversial. We propose a simple maneuver of laparoscopic trans-cystic duct stenting of the papilla during cholecystectomy, followed by elective stent-guided sphincterotomy, as an expedient option.

METHODS

We studied retrospectively 16 patients with choledocholithiasis first diagnosed in the course of laparoscopic cholecystectomy, treated with laparoscopic stenting of the papilla via the cystic duct using a short Cotton-Leung stent before completion of cholecystectomy. Elective stent-guided, needle-knife sphincterotomy and stone clearance was performed 2 to 3 weeks postoperatively.

RESULTS

Of 16 patients attempted, the procedure failed in one due to an impacted stone that prevented passage of the guidewire. Stenting time was 13 +/- 5 minutes (n = 15). Two stented patients had no stones at endoscopic retrograde cholangiography. Thirteen patients had successful elective stent-guided sphincterotomy with stone clearance without complications.

CONCLUSIONS

Laparoscopic biliary stenting combined with stent-guided sphincterotomy is a simple, safe, and cost-effective option for the management of uncomplicated choledocholithiasis.

Efficacy of routine laparoscopy for the acute abdomen

BACKGROUND

Laparoscopic surgery of selected acute abdominal conditions has been shown to be highly effective. Therefore, we investigated the diagnostic accuracy and therapeutic efficacy of routine laparoscopic surgery for the acute abdomen.

METHODS

After appropriate investigations, patients with acute abdomen, with or without a specific diagnosis, were offered the options of either laparoscopic or open surgery. Postoperatively, we analyzed the outcome measures of diagnostic accuracy, complications, and operating time of laparoscopy. The hospital stays for our patients were compared to case-matched controls.

RESULTS

The accuracy of laparoscopic diagnosis is the same as laparotomy. The 62% of our patients who were managed totally laparoscopically required shorter hospitalization than the case-matched controls treated by open operation. Morbidity was not increased by laparoscopy in patients who required conversion to open operation. The additional cost of laparoscopy appeared modest.

CONCLUSIONS

Routine laparoscopy for the acute abdomen is safe and accurate. Patients eligible for laparoscopic treatment also require less hospitalization time.

Laparoscopy-assisted jejunal resection for bleeding leiomyoma

We report a case of successful resection of a jejunal leiomyoma using a minimally invasive technique. By combining the procedures of push enteroscopy and laparoscopy, jejunal resection can be performed expeditiously without laparotomy.

In vitro effects of simulated gastric juice on swallowed metal objects: implications for practical management

BACKGROUND

Swallowed metal objects often pose a technical challenge for the endoscopist. We studied in vitro the effects of simulated gastric juice on metal objects commonly encountered in endoscopic practice and measured the physical-chemical changes.

METHOD

Razor blades, disc batteries, and pennies were incubated in simulated gastric juice at 37 degrees C. The weights of the objects were recorded hourly. When no change could be detected, the solution was subjected to mass spectrometry to verify absence of effect. The findings were correlated with clinical observation in one patient who swallowed razor blades repeatedly.

RESULTS

Dissolution of the razor blade was proportional to the duration of acid immersion. At 24 hours, the blades weighed 63% of the original weight. Double-edged razor blades could be broken with a snare at 15 hours. The thickened back of the single-edged blade totally dissolved in 2 hours. No leak of contents could be detected with disk batteries. Pennies were unaffected.

CONCLUSION

Corrosion of razor blades occurs rapidly in the normal stomach. Within 24 hours double-edged blades become fragile and can be broken with a snare. This observation may guide the timing of endoscopic removal. Modern disk batteries are acid resistant for 24 hours.

Client satisfaction data and quality improvement planning in managed mental health care organizations

Quality improvement (QI) planning is enhanced when TQM administrators ensure appropriate analysis of client satisfaction (CS) survey data. A cost-effective QI strategy is to shift "moderately satisfied" into "maximally satisfied" clients. Use of a categorical variable derived from CS data and development of a predictive model with Chi Square Automatic Interaction Detection (CHAID) produces recommendations for quality improvement.

Palliative gastrojejunostomy. A minimally invasive approach

Palliative bypass for neoplastic gastric outlet obstruction should be minimally invasive. We designed a laparoscopically assisted approach that appears to meet the need. The proximal jejunum is exteriorized by laparoscopy via an epigastric trocar-site incision. An EEA anvil is installed in the exteriorized jejunum, which is returned to the abdomen. Through this mini-incision, the anterior wall of the stomach is opened for insertion of the EEA stapler, which penetrates the posterior gastric wall. When snapped to the anvil and fired, an antecolic gastrojejunostomy is created. No mortality or anastomotic leak occurred in two cases. The operation and recovery appeared to be faster than historic controls. This operation is minimally invasive and expeditious, ideal for patients requiring palliative bypass.

One-on-one mentor-resident rotation for improving continuity of care in a surgical training program

The modern resident team, staffed by multiple attendings, often makes sacrifices on continuity of care due to scheduling conflicts. We investigated a one-on-one mentor-resident rotation where all clinical activities were synchronized to produce near-perfect continuity of care, and we compared the objective and subjective outcome measures to those of control rotations of the same resident during the same year. The results showed that continuity of care close to 100% was possible in such rotations, but work hours were increased by 25%. Also, the number of patients seen was decreased by over 50%. The rotation was well-received by both mentors and residents. Continuity of care per se can be improved by this rotation. However, theoretical disadvantages, mainly narrow training due to exposure to only one mentor and fewer patients, make it unsuitable for extended use.

Colectomy for sigmoid volvulus

PURPOSE

Volvulus of the sigmoid carries a high mortality. This minimally invasive technique is designed for poor-risk patients.

TECHNIQUE

Aided by laparoscopy, the mobile sigmoid is exteriorized through a mini-incision without preliminary dissection. The entire resection and anastomosis is performed on the surface of the abdomen. The options of end colostomy, primary anastomosis with or without fecal diversion, can all be used with this method.

RESULTS

No mortality or leakage occurred in four patients.

CONCLUSION

This rapid operation does not require advanced laparoscopic skills. Preliminary results should be confirmed by others.