Using human reliability analysis to detect surgical error in endoscopic DCR surgery

The aim of this study was to describe the nature of active skill-based errors occurring in endoscopic dacrocystorhinostomy (DCR) surgery. A human reliability analysis methodology was used to assess surgical error from observational capture data. Twelve endoscopic DCR operations performed by three different surgical trainees were video recorded. The steps (subtasks) of each operation were carefully analysed and common errors were documented. Specific errors that resulted in trauma to the nasal mucosa were noted. Execution errors were common, with errors of grasping being most frequent (67% of all execution errors). Most of these involved the Blakesley forceps. In total, there were 69 mucosal trauma hits. Inserting instruments into or withdrawing them from the nasal cavity with too much force or speed caused more than half of these. Incising with too much force resulting in 'overshoot' caused 34% of mucosal trauma. Trainee ENT surgeons should take particular care when inserting or withdrawing instruments from the nasal cavity and also when performing lacrimal sac or nasal mucosa incisions. Performance of these tasks with too much force was identified as a common and potentially avoidable cause of mucosal trauma. Further research is needed into the design and use of endoscopic sinus surgery instruments with the aim of avoiding the errors that were encountered.

1-[2-(4-nitrophenoxy)acetyl]pyrrolidin-2-one: an antiamnesic agent

The title compound, C(12)H(12)N(2)O(5), is a potential antiamnesic agent. The pyrrolidinone ring has an envelope conformation, and the central moiety is almost coplanar with the planes of the phenyl and pyrrolidinone rings. In the crystal structure, weak intermolecular C--H...O interactions link the molecules into a complex network that can be described by R(2)(2)(X) rings (X = 16, 20 and 26) and a C(12) chain.

Phylogenetic analysis of hemoplasma species: an international study

Nearly complete 16S rRNA gene sequences for feline and canine hemoplasma isolates from Europe, Australia, Africa, and Asia showed almost 100% identity to those previously reported for United States isolates. Partial sequences of the RNA subunit of the RNase P gene were also determined, and RNase P-based phylogenetic analysis showed that the hemoplasmas are most closely related to the members of the Mycoplasma pneumoniae group.

2-(2-Naphthyloxy)acetate derivatives. I. A new class of antiamnesic agents

The title compounds 1-(2-naphthyloxymethylcarbonyl)piperidine, C(17)H(19)NO(2), (I), and 3-methyl-1-(2-naphthyloxymethylcarbonyl)piperidine, C(18)H(21)NO(2), (II), are potential antiamnesics. In (II), the methyl-substituted piperidine ring is disordered over two conformations. The piperidine ring has a chair conformation in both compounds. In (I), the molecules are linked by weak intermolecular C-H.O interactions to give networks represented by C(4), C(6) and R(4)(4)(18) graph-set motifs, while in (II), weak intermolecular C-H.O interactions generate R(1)(2)(5), C(4) and C(7) graph-set motifs. The dihedral angle between the naphthalene moiety and the piperidine ring is 33.83 (7) degrees in (I), while it is 31.78 (11) and 19.38 (19) degrees for the major and minor conformations, respectively, in (II).

Complete heart block associated with lupus in a dog

A 5-year-old Poodle-cross was initially presented for exercise intolerance and difficulty in chewing and yawning. Some months later it acutely developed lethargy referable to complete heart block. Further investigations before and after permanent pacemaker implantation demonstrated Coombs-positive immune-mediated haemolytic anaemia, presumptive masticatory myositis and hypoadrenocorticism, suggesting the possibility of multisystem auto-immune disease. A diagnosis of systemic lupus erythematosus (SLE) was made based on these findings and a positive anti-nuclear antibody titre. It was thought that immune-mediated destruction of cardiac conduction tissues was responsible for the development of atrioventricular conduction block. Glucocorticoid deficiency was corrected using cortisone replacement therapy. SLE was controlled successfully for 10 months using azathioprine monotherapy until signs, subsequently shown to be due to subacute bacterial endocarditis, resulted in the death of the patient. Lupus should be considered as a potential underlying aetiology in dogs that develop heart block.

Diaphragmatic hernia in a cat mimicking a pulmonary mass

A seven-year-old castrated British shorthair cross cat was presented for coughing of five-weeks duration. Thoracic radiographs and an unguided bronchoalveolar lavage showed changes consistent with inflammatory airway disease. In addition, a soft tissue density was evident in the thoracic films between the heart and the diaphragm. Exploratory thoracotomy demonstrated a diaphragmatic hernia, probably congenital in origin, with incarceration of a portion of the hepatic parenchyma. The herniated portion of liver was resected surgically and the defect in the diaphragm closed. The cat was given a 10-day course of doxycycline post-operatively and the cough did not recur subsequently. In retrospect, the hernia was potentially an incidental problem, the cat's coughing being attributable to inflammatory airway disease.

Cryptococcus neoformans var. gattii in the koala (Phascolarctos cinereus): a review of 43 cases of cryptococcosis

Details of 11 previously reported cases and 32 new cases of cryptococcosis in captive and wild koalas were analysed. Cryptococcus neoformans var. gattii accounted for all 29 cases in which varietal status was determined. No age or sex predisposition was observed. The respiratory tract was the primary focus of disease in 77% of cases. Although the lower respiratory tract was affected most commonly (60% of cases), 30% of cases had upper respiratory tract lesions and 14% had both. Dissemination was common, especially to the central nervous system (37% cases). Local extension to surrounding tissues was a feature of upper respiratory tract disease. Other tissues showing cryptococcal invasion included lymph nodes (19%), gastrointestinal tract (12%), kidneys (12%), spleen (9%) and skin (7%). Only three cases (7%) had no respiratory tract or central nervous system involvement, two cases of primary skin inoculation and one case of primary lymphadenopathy. Late presentation was a likely factor in the high proportion of cases with disseminated disease (40%). The proportion of koala cases with involvement of the central nervous system, lower respiratory tract and skin, parallels what has been reported for immunocompetent people. Cryptococcosis in the koala appears to be an excellent naturally occurring model for examination of the cryptococcal host-parasite relationship in all species.

Disseminated melioidosis in two cats

Melioidosis was diagnosed in two cats at necropsy. The first cat presented with jaundice and anaemia but died of overwhelming sepsis soon after admission, despite blood transfusion and other supportive measures. The second cat died several days after developing neurological signs; an infected digital wound may have been the primary focus of infection in this patient. The cats had presumably acquired the infection in Malaysia and northern Australia, respectively, and in both cases disease may have represented reactivation of a latent infection brought on by the stress of relocation. The epidemiology, clinical presentation, diagnosis and treatment of melioidosis are discussed from a feline perspective.

Avian cryptococcosis

Clinical and laboratory findings in 15 unreported cases of avian cryptococcosis from Australia were collated and contrasted with 11 cases recorded in the literature. Cryptococcus species produced localized invasive disease of the upper respiratory tract of captive parrots living in Australia. This resulted in signs referable to mycotic rhinitis or to involvement of structures contiguous with the nasal cavity, such as the beak, sinuses, choana, retrobulbar space and palate. Parrots of widely differing ages were affected and of the seven birds for which sex was determinable, six were male. Cryptococcus bacillisporus (formerly C. neoformans var. gattii) accounted for four of five infections in which the species or variety was determinable, suggesting that exposure to eucalyptus material may be a predisposing factor. In these cases, Cryptococcus appeared to behave as a primary pathogen of immunocompetent hosts. One tissue specimen was available from an Australian racing pigeon with minimally invasive subcutaneous disease; immunohistology demonstrated a C. neoformans var. grubii (formerly C. neoformans var. neoformans serotype A) infection, presumably subsequent to traumatic inoculation of yeast cells into the subcutis. Two similar cases had been reported previously in pigeons domiciled in America. Data for parrots, one pigeon and other birds studied principally in America and Europe (and likely infected with C. neoformans) suggested a different pattern of disease, more suggestive of opportunistic infection of immunodeficient hosts. In this cohort of patients, the organism was not restricted to cool superficial sites such as the upper respiratory tract or subcutis. Instead, infections typically penetrated the lower respiratory tract or disseminated widely to a variety of internal organs. Finally, three captive North Island brown kiwis, one residing in Australia, the other two in New Zealand, died as a result of severe diffuse cryptococcal pneumonia (two cases) or widely disseminated disease (one case). C. bacillisporus strains were isolated from all three cases, as reported previously for another kiwi with disseminated disease in New Zealand.

Antemortem diagnosis of canine neural angiostrongylosis using ELISA

A 5-month-old female Kelpie developed paraparesis, hind limb ataxia and spinal hyperaesthesia 4 days after ovariohysterectomy. Neurological examination demonstrated upper motor neuron signs in the pelvic limbs with lower motor neuron signs in the tail. Cerebrospinal fluid analysis demonstrated an increased protein concentration and marked eosinophilic pleocytosis. The dog was known to have eaten rats, snails and slugs. A tentative diagnosis of neural angiostrongylosis was made and later confirmed using an ELISA based on soluble antigens obtained from larval 4 Angiostrongylus cantonensis. Antibody titres from the patient's serum and CSF were 800 and 6400, respectively. The dog was treated successfully with prednisolone. ELISA testing of serum may provide a non-invasive means for diagnosing neural angiostrongylosis in dogs.

Cryptococcosis in ferrets: a diverse spectrum of clinical disease

Cryptococcosis was diagnosed in seven ferrets (five from Australia; two from western Canada) displaying a wide range of clinical signs. Two of the ferrets lived together. One (5-years-old) had cryptococcal rhinitis and presented when the infection spread to the nasal bridge. Its sibling developed cryptococcal abscessation of the right retropharyngeal lymph node 12 months later, soon after developing a severe skin condition. DNA fingerprinting and microsatellite analysis demonstrated that the two strains isolated from these siblings were indistinguishable. Two ferrets (2- to 3-years-old) developed generalised cryptococcosis: one had primary lower respiratory tract disease with pneumonia, pleurisy and mediastinal lymph node involvement, while in the other a segment of intestine was the primary focus of infection with subsequent spread to mesenteric lymph nodes, liver and lung. The remaining three ferrets (1.75 to 4-years-old) had localised disease of a distal limb, in one case with spread to the regional lymph node. Cryptococcus bacillisporus (formerly C. neoformans var gattii) accounted for three of the four infections in Australian ferrets where the biotype could be determined. The Australian ferret with intestinal involvement and the two ferrets from Vancouver had C. neoformans var grubii infections.

Limited diversity among human isolates of Bartonella henselae

A study of 59 isolates of Bartonella henselae reveals relatively limited diversity among those of human origin (n = 28). Either of two distinct alleles of both gltA and 16S ribosomal DNA (rDNA) was found in all isolates, with a high level of congruity between 16S and gltA inheritance among proven human pathogens. Human isolates from all over Eastern Australia were most commonly 16S rDNA (Bergmans) type I, with the same gltA allele as the type strain (Houston-1). Comparable feline isolates were more commonly 16S type II, with less congruity of inheritance between 16S and gltA alleles. Previously described arbitrarily primed PCR and EagI-HhaI infrequent restriction site PCR fingerprinting techniques separated Bartonella species effectively but lacked discriminating power within B. henselae. Examination of the 16-23S intergenic spacer region revealed for several strains several point mutations as well as a repeat sequence of unknown significance which is readily detected by HaeIII restriction fragment length polymorphism analysis. The bacteriophage-associated papA gene was present in all isolates. Enterobacterial repetitive intergenic consensus PCR proved to be a useful and robust typing tool and clearly separated human isolates (including imported strains) from the majority of feline isolates. Our data are consistent with published evidence and with previous suggestions of intragenomic rearrangements in the type strain and suggest that human isolates come from a limited subset of B. henselae strains. They strengthen arguments for careful exploration of genotype-phenotype relationships and for the development of a multilocus enzyme electrophoresis and multilocus sequence typing-based approach to the phylogeny of B. henselae.

2002: Hiatal hernia in a puppy

A sliding hiatal hernia (where the terminal oesophagus, oesophagogastric junction and part of the stomach move cranially through a diaphragmatic defect) was diagnosed in a 4-month-old, Shar-Pei puppy presented for evaluation of regurgitation. The diagnosis was confirmed using radiography. Herniorraphy consisted of repositioning the stomach within the abdomen, plicating the diaphragmatic hiatus and performing a tube gastropexy to the left abdominal wall. Veterinary practitioners should have a high index of suspicion of hiatal hernia in young puppies, particularly Shar-Peis and British Bull Dogs, that present with persistent vomiting or regurgitation.

The relationship between the thyroid gland and the liver

Thyroxine and tri-iodothyronine are essential for normal organ growth, development and function. These hormones regulate the basal metabolic rate of all cells, including hepatocytes, and thereby modulate hepatic function; the liver in turn metabolizes the thyroid hormones and regulates their systemic endocrine effects. Thyroid dysfunction may perturb liver function, liver disease modulates thyroid hormone metabolism, and a variety of systemic diseases affect both organs. We highlight the intricate relations between the thyroid gland and the liver in health and disease.

Assessment of the CASP4 fold recognition category

We present the assessment of the CASP4 fold recognition category. The tasks we had to execute include the splitting of multidomain targets into single domains, the classification of target domains in terms of prediction categories, the numerical evaluation of predictions, the mapping of numerical scores to quality indices, the ranking of predictors, the selection of top-performing groups, and the analysis and critical discussion of the state of the art in this field. The 125 fold recognition groups were assessed by a total score that summarizes their performance over all targets and a quality score reflecting the average quality of the submitted models. Most of the top-performing groups achieved respectable results on both scores simultaneously. Several groups submitted models that were much closer to the respective target structures than any of the known folds in the Protein Data Bank. The CASP4 assessment included the automated servers of the parallel CAFASP experiment. For the total score, the highest rank achieved by a fully automated server is 12. Two thirds of the predictors have rather low scores.

Spontaneous hepatic rupture in six cats with systemic amyloidosis

Spontaneous hepatic rupture, secondary to the accumulation of hepatic amyloid, was diagnosed in six cats over a two-year period. Previous reports of feline hepatic amyloidosis have documented clusters of cases from breeding catteries. Most affected cats have been Siamese or a related breed and the disease is generally regarded as familial. In contrast, the cases presented here were sporadic, with relatives and other cats in the household not clinically affected. They included a Devon rex, a breed not previously reported with this condition, and a domestic shorthair. Clinical signs in three of these cases had, prior to referral, been misinterpreted as resulting from blunt trauma, immune-mediated haemolysis or a coagulopathy. Antemortem diagnostic features, including new data on the value of hepatic ultrasonography and fine-needle aspirate cytology, are reported. These cases illustrate how the course of this disease can vary between individuals and that, despite the dramatic underlying pathology, hepatic amyloidosis can present a diagnostic challenge and should be suspected in any young adult cat with consistent clinical signs, irrespective of breed or environment.

Renal Transplantation - Calcutta Experience

31 renal transplant procedures have been performed at this centre. Renal donors were father in 4, mother in 4, brother in 12, sister in 4, brother-in-law in 1 and wives in 6 cases. Median age of recipients and donors was 35.2 years (20-55) and 38.3 years (24-60) respectively. After a mean follow up of 15.7 months (2-40), graft survival was 96.7% and patient survival 90-3%. Three patients (9.6%) required surgical re-exploration, one each for, peri-graft haematoma, arterial kink and graft artery thrombosis. 6 patients (19.3%) required anti rejection therapy with resultant complete normalisation of graft functions. Medical complications noted were post transplant diabetes mellitus in 6 (19.3%), azathihoprine induced bone marrow suppression in 1(3.2%), tuberculosis in 2 (6.4%), post transplant erythrocytosis in 2 (6.4%) and recurrent urinary tract infection (UTI) in one (3.2%) patients. 3 patients (9.6%) died with functioning graft, one due to lung infection and the other due to haemorrahagic pancreatitis and third due to infective endocarditis.

Cryptococcus neoformans var. gattii in the koala (Phascolarctos cinereus): serological evidence for subclinical cryptococcosis

Cryptococcus neoformans var. gattii has been shown to have a strong association with eucalypts frequently used by koalas and, not surprisingly, it has been shown to colonize the nasal cavities of koalas. The progression from nasal colonization to tissue invasion is critical to understanding the pathogenesis of cryptococcosis in this species and provides a model for pathogenesis of cryptococcosis in other species. Cryptococcal antigenaemia was detected in twenty-eight healthy koalas from three different regions. This was interpreted as representing limited subclinical disease. One koala developed cryptococcal pneumonia 6 months after leaving the study, whereas another developed cryptococcal meningoencephalitis during the course of the study. Opportunistic necropsies on ten antigen-positive koalas resulted in discovery of small cryptococcal lesions in two (paranasal sinus and lung, respectively). Our data suggest that cryptococcal antigenaemia occurs commonly in koalas, especially in areas with a high environmental presence of C n. var. gattii. Subclinical disease appears most likely to manifest as a small focal lesion in the respiratory tract. Possible outcomes include elimination by an effective immune response, quiescence with possibility of later re-activation or direct progression to overt disease. Symptomatic and subclinical cases showed differences in levels of antigenaemia. The data presented have significant implications for koalas in captivity.