Laparoscopic treatment of rectal prolapse: experience gained in a prospective multicenter study

BACKGROUND

We report the findings of a prospective multicenter observational study carried out by the Study Group for Laparoscopic Colorectal Surgery on patients undergoing laparoscopic or laparoscopic-assisted surgery for rectal prolapse. The study investigated the safety of various laparoscopic techniques in terms of perioperative and postoperative general and technique-specific complications and compared the results with those reported for open surgery in this area.

METHODS

Of the 150 patients undergoing laparoscopic or laparoscopic-assisted colorectal surgery for rectal prolapse 124 received rectopexy combined with resection and 26 rectopexy alone. In 85 patients a mesh was employed during rectopexy. The conversion rate was 5.3%.

RESULTS

Perioperative complications (21 surgical and 35 general perioperative) were recorded in 37 patients (24.7%). The reoperation rate was 5.3% (bleeding 2, anastomotic leak 2, ileus 4). No procedure-specific perioperative complications were observed. In particular, reduced surgical trauma led to fewer severe postoperative complications such as cardiopulmonary problems (3.3%).

CONCLUSIONS

The techniques of conventional prolapse surgery can readily be translated to the laparoscopic modality, since oncological criteria do not have to be considered. The usually elderly patients in this group benefit to a particular degree from the known advantages associated with reduced surgical trauma. Perioperative morbidity is determined largely by the surgeon's experience. We therefore believe that rectal prolapse is a suitable indication for the minimally invasive modality in the hands of trained surgeons.

Measuring staff support in services for people with intellectual disability: the Staff Support and Satisfaction Questionnaire, Version 2

Social support is an important determinant of well-being, including the stress experienced within the work setting. The present paper reports on the development of the Staff Support and Satisfaction Questionnaire (3SQ), from a previously published measure: the Staff Support Questionnaire. The 3SQ was piloted with 21 health professionals and examined for evidence of test-retest reliability with 24 staff. Data on internal reliability were collected on three occasions from a total sample of 177 staff. The validity of the 3SQ was examined in four studies with a total of 238 staff by testing it against validated measures of psychological well-being. The data showed that the total scale had a high level of test--retest reliability (rs=0.82, P < 0.001) and consistently high internal reliability. Three out of the four validity studies showed statistically significant inverse relationships between the total scale and measures of psychological well-being. The weakest link was the 'Supportive People' subscale. The reliability and validity studies suggest that the psychometric properties of the 3SQ are generally robust, except for the 'Supportive People' subscale, which should be interpreted with caution.

Subjective judgements of quality of life: a comparison study between people with intellectual disability and those without disability

The present study investigated the relationship between objective and subjective measures of quality of life (QoL), and in particular, health status and primary care services. Thirty-one people with intellectual disability (ID) were interviewed using a QoL questionnaire. Thirty-one matched controls from the general population filled in a parallel questionnaire. The results in both groups support the findings of many researchers which indicate that satisfaction with aspects of life is generally high (i.e. approximate 75% of maximum possible satisfaction). The present study also confirms previous findings which indicate that satisfaction with aspects of life does not generally correlate with objective circumstances in either group. The importance that people attach to aspects of their lives did not generally correlate with their objective circumstances or their satisfaction with life. However, people with ID attached greater importance to all aspects of their lives than those without disability. This may be linked to their aspirations, preferences and opportunities for choice, and therefore, these factors may be a more meaningful way of considering their QoL. The present findings call into question the use of satisfaction as a general measure of QoL, and also indicate that the use of importance as a mediating variable in understanding satisfaction may not be a solution. The participants with ID had poorer health than the controls, and were significantly less satisfied with their health. Contrary to other findings, the present participants with ID reported that they had received more health checks than the controls over the previous year. Half of these checks had been carried out by 'special' services rather than primary care services.

Postural balance in children with cerebral palsy

Postural control deficits have been suggested to be a major component of gait disorders in cerebral palsy (CP). Standing balance was investigated in 23 ambulatory children and adolescents with spastic diplegic CP, ages 5 to 18 years, and compared with values of 92 children without disability, ages 5 to 18 years, while they stood on a force plate with eyes open or eyes closed. The measurements included center of pressure calculations of path length per second, average radial displacement, mean frequency of sway, and Brownian random motion measures of the short-term diffusion coefficient, and the long-term scaling exponent. In the majority of children with CP (14 of 23) all standing balance values were normal. However, approximately one-third of the children with CP (eight of 23) had abnormal values in at least two of the six center of pressure measures. Thus, mean values for path length, average radial displacement, and diffusion coefficient were higher for participants with CP compared with control individuals with eyes open and closed (p<0.05). Mean values for frequency of sway and the long-term scaling exponent were lower for participants with CP compared with control participants (p<0.05). Increased average radial displacement was the most common (nine of 23) postural control deficit. There was no increase in abnormal values with eyes closed compared with eyes open for participants with CP, indicating that most participants with CP had normal dependence on visual feedback to maintain balance. Identification of those children with impaired standing balance can delineate factors that contribute to the patient's gait disorder and help to guide treatment.

The crystal structures of Phascolopsis gouldii wild type and L98Y methemerythrins: structural and functional alterations of the O2 binding pocket

Reported are the X-ray crystal structures of recombinant Phascolopsis gouldii methemerythrin (1.8-A resolution) and the structure of an O2-binding-pocket mutant, L98Y methemerythrin (2.1-A resolution). The L98Y hemerythrin (Hr) has a greatly enhanced O2 affinity, a slower O2 dissociation rate, a larger solvent deuterium isotope effect on this rate, and a greater resistance to autoxidation relative to the wild-type protein. The crystal structures show that the hydrophobic binding pocket of Hr can accommodate substitution of a leucyl by a tyrosyl side chain with relatively minor structural rearrangements. UV/vis and resonance Raman spectra show that in solution L98Y methemerythrin contains a mixture of two diiron site structures differing by the absence or presence of an Fe(III)-coordinated phenolate. However, in the crystal, only one L98Y diiron site structure is seen, in which the Y98 hydroxyl is not a ligand, but instead forms a hydrogen bond to a terminal hydroxo/aqua ligand to the nearest iron. Based on this crystal structure, we propose that in the oxy form of L98Y hemerythrin the non-polar nature of the binding pocket favors localization of the Y98 hydroxyl near the O2 binding site, where it can donate a hydrogen bond to the hydroperoxo ligand. The stabilizing Y98OH-O2H-interaction would account for all of the altered O2 binding properties of L98Y Hr listed above.

Preparation and X-ray crystallographic analysis of recombinant obelin crystals diffracting to beyond 1.1 A

Crystals of recombinant obelin, the Ca(2+)-regulated photoprotein from the marine hydroid Obelia longissima, have been grown from a solution containing PEG 8000 and potassium phosphate. Hexaminecobalt trichloride was used as an additive to increase the chance of crystallization. The crystals grow in a light yellow cubic form (0.5 x 0.5 x 0.45 mm) which diffracts to beyond 1.1 A resolution. The crystals belong to the space group C2, with unit-cell parameters a = 83.43, b = 54.92, c = 52.99 A, beta = 112.00 degrees. The asymmetric unit contains one molecule. Crystals exposed to calcium ion before and after X-ray irradiation emit light, confirming that the crystals consist of an active photoprotein.

An alternative system for cerebrovascular reconstructions: non-penetrating arcuate-legged clips

Non-penetrating, arcuate-legged titanium clips (VCS) have been utilized successfully over the past five years for a variety of cerebrovascular reconstructions. These applications, including both micro and macrovascular reconstructions, their clinical outcomes and technical considerations are described. Applications include patch angioplasty of cervical carotid endarterectomies, superficial temporal to middle cerebral artery 'bypass' procedures, Takayasu's arteritis and cavernous carotid reconstructions. The non-penetrating clip has proven to be a safe and reliable alternative to suture for these demanding reconstructions. Clips provide the advantages of improved anastomotic compliance, reduced operative time, and reduced incidence of post-operative anastomotic intimal hyperplasia and stenosis. Clip related pitfalls are discussed with recommendations regarding usage.

Augmentative and alternative communication: Relevance for physiotherapists

Communication is one of the critical components in determining quality of life of individuals and families. All members of the transdisciplinary rehabilitation team therefore need to develop the knowledge and skills to communicate effectively with clients with little or no speech. This involves creating opportunities for communicative interaction and facilitation of functional communication. The field of augmentative and alternative communication (AAC) provides strategies and techniques which facilitate the interaction process and is applicable to a wide range of medical conditions which may impact on the functionality and intelligibility of speech. These strategies are classified either as aided or unaided. The role of the physiotherapist in AAC assessment and intervention is explored in the context of transdisciplinary teamwork. The importance of exposing students to AAC as part of the undergraduate and postgraduate training programs for physiotherapists is discussed.

Electromyographic test to differentiate mild diplegic cerebral palsy and idiopathic toe-walking

The purpose of this study was to determine whether children with mild spastic diplegic cerebral palsy (CP) could be differentiated from those with idiopathic toe-walking (ITW) based on an obligatory coactivation during voluntary contraction of the quadriceps or gastrocnemius. Twenty-four subjects participated in this study, eight children with mild spastic diplegia CP, eight with ITW, and eight age-matched controls. Measurements included passive range of motion and surface electromyographic recordings of the lateral quadriceps and lateral gastrocnemius. Electromyographic recordings were obtained during resisted knee extension with knee flexed 30 degrees, isometric quadriceps contraction with knee extended (quad set), active plantarflexion, and during gait. The range-of-motion values were not different between the CP and ITW subjects, with the exception of the popliteal angle, which was greater in subjects with CP, with an overlap in values. Gait electromyography showed premature firing of gastrocnemius in swing in both groups of subjects compared with controls. During resisted knee extension and quad set, the mean duration of gastrocnemius coactivation in subjects with CP was high: 86% and 86% compared with 20% and 35% for the subjects with ITW and 0.4% and 3% for controls, respectively. Voluntary plantarflexion did not consistently elicit coactivation of the quadriceps. The results suggest that electromyographic testing of resisted knee extension and quad set to identify gastrocnemius coactivation can help differentiate patients with mild CP from those with ITW.

Rheological properties of PMMA bone cements during curing

The rheological behaviour of poly(methyl methacrylate) bone cements has been characterised during the curing phase using an oscillating parallel plate rheometer. Viscosity has been measured as a function of time for a range of commercial cements showing different viscosity-time profiles. Measurements have been made over a range of temperatures from 19-25 degrees C, and the results show a strong dependence of rate of viscosity rise on temperature. Viscoelastic parameters, such as storage modulus, loss modulus and phase angle have been obtained and show the change from primarily viscous to elastic behaviour as the cements set. It is suggested that these parameters more completely describe the rheological behaviour of bone cements than viscosity alone and may provide a better measure of handling and setting characteristics.

Development of a novel, nonimmunogenic, soluble human TNF receptor type I (sTNFR-I) construct in the baboon

Pharmacokinetics and immunogenicity of six different recombinant human soluble p55 tumor necrosis factor (TNF) receptor I (sTNFR-I) constructs were evaluated in juvenile baboons. The constructs included either an sTNFR-I IgG1 immunoadhesin (p55 sTNFR-I Fc) or five different sTNFR-I constructs covalently linked to polyethylene glycol. The constructs were administered intravenously three times, and pharmacokinetics and immunogenicity were examined over 63 days. All of the constructs were immunogenic, with the exception of a 2.6-domain monomeric sTNFR-I. To evaluate whether the nonimmunogenic 2.6-domain monomeric construct could protect baboons against TNF-alpha-induced mortality, baboons were pretreated with 1, 5, or 10 mg/kg body wt and were compared with baboons receiving either placebo or 1 mg/kg body wt of the dimeric 4.0-domain sTNFR-I construct (n = 3 each) before lethal Escherichia coli bacteremia. The monomeric construct protected baboons and neutralized TNF bioactivity, although greater quantities were required compared with the dimeric 4.0-domain sTNFR-I construct. We conclude that E. coli-recombinant-derived human sTNFR-I constructs can be generated with minimal immunogenicity on repeated administration and still protect against the consequences of exaggerated TNF-alpha production.

Structural basis for the emission of violet bioluminescence from a W92F obelin mutant

Mutation of the Trp92 that is known to lie within the active site of the photoprotein obelin from Obelia longissima, results in a shift of the bioluminescence color from blue (lambda(max)=485 nm) to violet. The corrected spectrum shows a new band with lambda(max)=410 nm now contributing equally to the one at longer wavelength. The crystal structure of this W92F obelin determined at 1.72 A resolution shows that there is no significant change in the dimensions of the active site between WT obelin (recombinant Ca2+-regulated photoprotein from Obelia longissima) and the mutant. It is proposed that the bioluminescence spectral shift results from removal of a hydrogen bond from the indole of W92 nearby a hydroxyl belonging to the 6-phenyl substituent of the substrate coelenterazine. Propagation of this change through a conjugated bond system in the excited state of the product coelenteramide affects the coupling of the N1-position and the hydrogen-bonded Y138.

Ruptured abdominal aortic aneurysms: clinical presentation in Auckland 1993-1997

BACKGROUND

Rupture of an abdominal aortic aneurysm (RAAA) carries a reported mortality rate in the range of 32-95%. Survival requires prompt diagnosis and surgical management. The presenting features, however, are varied, often insidious and potentially misleading with Osler noting nearly 100 years ago that a correct premortem diagnosis was achieved in only 33% of cases. The present study aims to review our present accuracy in diagnosing this condition and outline demographic and presenting features of patients with RAAA.

METHODS

A review was undertaken of hospital and Coroner's files of all patients residing in the Auckland Coronial region who had RAAA between 1 January 1993 and 31 December 1997.

RESULTS

Three hundred and twenty-nine cases of RAAA were identified, and they occurred most commonly in the 8th decade. The male:female ratio was 3:1 and at least 73% of patients were Caucasian. The overall mortality was 71%. Nearly half underwent surgery and the hospital averaged mortality rate was 46%. No patient survived without surgery. Classic presenting features of RAAA were absent in many cases. Abdominal pain, back pain and a palpable mass occurred in only 49%, 36% and 18% of patients, respectively. Other common presenting symptoms included vomiting, general malaise and pelvic or hip pain. Forty-three patients (16%) were initially misdiagnosed.

CONCLUSIONS

Although our ability to correctly diagnose a RAAA has improved since Osler's time, the initial misdiagnosis rate of 16% leaves no room for complacency. Ruptured abdominal aortic aneurysms must be included in the differential diagnosis of any patient over the age of 55 years who presents with shock, even if the pain is non-specific or atypical.

Spirocyclic nonpeptide glycoprotein IIb-IIIa antagonists. Part 1: design of potent and specific 3,9-diazaspiro[5.5]undecanes

The synthesis and biological activity of novel glycoprotein IIb-IIla antagonists containing the 3,9-diazaspiro[5.5]undecane nucleus are described. The potent activity of these compounds as platelet aggregation inhibitors demonstrates the utility of the spirocyclic structures as a central template for nonpeptide RGD mimics.

Spirocyclic nonpeptide glycoprotein IIb-IIIa antagonists. Part 2: design of potent antagonists containing the 3-azaspiro[5.5]undecanes

The synthesis and biological activity of novel glycoprotein IIb-IlIa anatagonists containing 3-azaspiro[5.5]undec-9-yl nucleus are described. The potent activity of these compounds as platelet aggregation inhibitors demonstrates the utility of the monoazaspirocyclic structure as central template for nonpeptide RGD mimics.

Sports doctors' resuscitation skills under examination: do they take it seriously?

As 64% of sports medicine doctors were unable to show proficiency at basic life support and assessment and management of a seriously injured patient with a potential spinal injury in the last two examinations for a University of Bath diploma in sports and exercise medicine, it was decided that a reminder is required of the importance of acquiring, at the very least, some basic resuscitation skills. An analysis and comment on the results from the first aid component of the examination is also presented.

The extra domain A of fibronectin activates Toll-like receptor 4

Cellular fibronectin, which contains an alternatively spliced exon encoding type III repeat extra domain A (EDA), is produced in response to tissue injury. Fragments of fibronectin have been implicated in physiological and pathological processes, especially tissue remodeling associated with inflammation. Because EDA-containing fibronectin fragments produce cellular responses similar to those provoked by bacterial lipopolysaccharide (LPS), we examined the ability of recombinant EDA to activate Toll-like receptor 4 (TLR4), the signaling receptor stimulated by LPS. We found that recombinant EDA, but not other recombinant fibronectin domains, activates human TLR4 expressed in a cell type (HEK 293 cells) that normally lacks this Toll-like receptor. EDA stimulation of TLR4 was dependent upon co-expression of MD-2, a TLR4 accessory protein. Unlike LPS, the activity of EDA was heat-sensitive and persisted in the presence of the LPS-binding antibiotic polymyxin B and a potent LPS antagonist, E5564, which completely suppressed LPS activation of TLR4. These observations provided a mechanism by which EDA-containing fibronectin fragments promote expression of genes involved in the inflammatory response.

Zirconium speciation in lactate solutions and polyacrylate gels

Controlling gelation kinetics is an important objective for several applications (ceramic and thin film syntheses, reduction in permeability of porous rock, etc). There is a growing interest in studying the gelation of polymers by zirconium, a crosslinker of lower toxicity than the chromium which is still commonly used. XAS at the Zr K-edge was performed at the European Synchrotron Radiation Facility (ESRF) on the BM32 beamline. The fluorescence detection was used to carry out successful in situ speciation at concentrations as low as 36 ppm. The Zr speciation was determined both in ZrLa (where La stands for lactate) aqueous solutions and in gels of a terpolymer of acrylamide having 2% of zirconium reactive acrylate side groups and 2% of sulfonate groups introduced to prevent syneresis. XANES results show that Zr is always in a dodecahedral geometry. In ZrLa solutions. EXAFS results indicate that Zr species grow from a dimer Zr2(La)6 to a tetramer (Zr4(La)x) and then to larger polymers resulting from tetramer associations, as the Zr concentration decreases from 51840 ppm to 36ppm. In polymer gels, Zr species appear to be dimers at pH 6 while tetramers are found when gelation occurred at pH 7. Calculations taking into account multiple scattering effects as well as dynamic molecular calculation confirmed conclusions derived from conventional EXAFS analysis.

Health management in the new millennium. Technology brings value

Informatics tools and agreements, evidence-based guidelines and principles, narrowed practice variation and better knowledge of appropriate and cost-effective techniques for managing health could allow us to control much of the rising cost of health care arising each year from increases in the volume and intensity of medical services, determined by clinical decisions.

Bereavement education for childcare professionals

Bereavement is a stressor that affects not only the child but also the whole family. Children need time and support to come to terms with their grief. Current evidence suggests that professionals feel ill equipped to deal with these issues. Inter-professional, multi-agency collaboration and support can provide effective, integrated and supportive services. A 12-day modular course was developed within the Exeter Community Trust and accredited by the University of Plymouth.

Ultrasonic assessment of physiological echo-contrast agent distribution in brain parenchyma with transient response second harmonic imaging

OBJECTIVES

The present study was designed to provide normal data of transient response second harmonic imaging (TRSHI) examinations of cerebral echo contrast enhancement using different modes of electrocardiogram (ECG) gating and echo-contrast agent doses.

MATERIALS AND METHODS

Fifty-five patients were examined in an axial diencephalic plane of section using the transtemporal acoustic bone window. TRSHI examinations (ECG gating: systolic, frame-rate once every 2 cardiac cycles = "basical instrument setting") could be performed in 50 individuals with adequate insonation conditions after application of 4 g of a galactose-based microbubbles suspension in a concentration of 400 mg/ml. For comparison, diastolic ECG gating (20 patients), cardiac-cycle triggering frequency of once every 2 seconds (15 patients), or an echo contrast agent dose of 2 g Levovist (15 patients) were used. Analysis of peak intensities (PIs) and areas under the curve (AUCs) was done in posterior (region of interest [ROI]a) and anterior (ROIb) parts of the thalamus, in the lentiform nucleus (ROIc), and the white matter (ROId).

RESULTS

In 41 patients with basical instrument setting, characteristic time intensity curve (TIC) could be detected in all ROIs. In ROIa (90%) and ROIb (82%), focal contrast enhancement was most difficult to visualize, and in ROIc and ROId, characteristic TICs were observable in more than 90% of the examinations. Background subtracted PIs and AUCs were significantly higher in ROIc (mean PI: 12.2 +/- 8 acoustic units [AUs]; mean AUC: 598.8 +/- 451.1 AU x Cardiac cycles), and ROId (11.8 +/- 6.9; 559.2 +/- 404) as compared to ROIa (8.3 +/- 5.2; 368.9 +/- 242.7) and ROIb (7.1 +/- 4.7; 298.2 +/- 199.1) (P < .0001). Values for corresponding examinations with a diastolic ECG gating and a cardiac cycle triggering frequency of once every 2 seconds were not different as compared to the basical instrument setting. A 4 g Levovist dose increased the portion of typical TIC in all ROIs. PI of 4 g examinations were significantly higher in ROId and ROIb as compared to the 2 g examination.

CONCLUSION

Our findings indicate that TRSHI allows noninvasive assessment of focal cerebral contrast enhancement in the majority of patients with adequate insonation conditions. This study provides data about normal quantitative and qualitative TRSHI values in patients without cerebrovascular diseases. A dose of 4 g Levovist is recommended in those individuals with inaccurate echo contrast enhancement using the 2 g dose.