Differential capacity of phragmites ecotypes in remediation of inorganic contaminants in coastal ecosystems: Implications for climate change

Remediating inorganic pollutants is an important part of protecting coastal ecosystems, which are especially at risk from the effects of climate change. Different Phragmites karka (Retz) Trin. ex Steud ecotypes were gathered from a variety of environments, and their abilities to remove inorganic contaminants from coastal wetlands were assessed. The goal is to learn how these ecotypes process innovation might help reduce the negative impacts of climate change on coastal environments. The Phragmites karka ecotype E1, found in a coastal environment in Ichkera that was impacted by residential wastewater, has higher biomass production and photosynthetic pigment content than the Phragmites karka ecotypes E2 (Kalsh) and E3 (Gatwala). Osmoprotectant accumulation was similar across ecotypes, suggesting that all were able to successfully adapt to polluted marine environments. The levels of both total soluble sugars and proteins were highest in E2. The amount of glycine betaine (GB) rose across the board, with the highest levels being found in the E3 ecotype. The study also demonstrated that differing coastal habitats significantly influenced the antioxidant activity of all ecotypes, with E1 displaying the lowest superoxide dismutase (SOD) activity, while E2 exhibited the lowest peroxidase (POD) and catalase (CAT) activities. Significant morphological changes were evident in E3, such as an expansion of the phloem, vascular bundle, and metaxylem cell areas. When compared to the E3 ecotype, the E1 and E2 ecotypes showed striking improvements across the board in leaf anatomy. Mechanistic links between architectural and physio-biochemical alterations are crucial to the ecological survival of different ecotypes of Phragmites karka in coastal environments affected by climate change. Their robustness and capacity to reduce pollution can help coastal ecosystems endure in the face of persistent climate change.

Evaluating climate change impacts on reef environments via multibeam echosounder and Acoustic Doppler Current profiler technology

Crucial to the Earth's oceans, ocean currents dynamically react to various factors, including rotation, wind patterns, temperature fluctuations, alterations in salinity and the gravitational pull of the moon. Climate change impacts coastal ecosystems, emphasizing the need for understanding these currents. This study explores multibeam echosounder (MBES), specifically R2-Sonic 2020 instrument, offering detailed seabed information. Investigating coral reefs, rocky reefs and artificial reefs aimed to map seafloor currents movement and their climate change responses. MBES data viz. Bathymetry and backscatter were classified and acoustic doppler current profiler (ADCP) ground data were validated using random forest regression. Results indicated high precision in currents speed measurement i.e. coral reefs with 0.96, artificial reefs with 0.94 and rocky reefs with 0.97. Currents direction accuracy was notable in coral reefs with 0.85, slightly lower in rocky reefs with 0.72 and artificial reefs with 0.60. Random forest identified sediment and backscatter as key for speed prediction while direction relies on bathymetry, slope and aspect. The study emphasizes integrating sediment size, backscatter, bathymetry and ADCP data for seafloor current analysis. This multibeam data on sediments and currents support better marine spatial planning and determine biodiversity patterns planning in the reef area.

Evaluation on microalgae for the production of bio-chemicals and electricity

Recent advancement in biophotovoltaic systems using microalgae, coupled with biorefinery approach, would improve economy-feasibility in production. The major concern is its commercial strength in terms of scalability, strain selection and extraction procedure cost. It must compete with conventional feedstocks such as fossil fuels. This project proposes to enhance the economic feasibility of microalgae-based biorefinery by evaluating their performance for bio-electricity, bio-diesel and carotenoids production in a single cycle. The first part of the study was to construct and select a Bio-bottle Voltaic (BBV) device that would allow microalgae to grow and produce bioproducts, as well as generate the maximum current output reading derived from the microalgae's photosynthesis process. The second phase consisted of a 25-day investigation into the biorefinery performance of six different microalgal species in producing bio-electricity, bio-diesel and carotenoid in a prototype BBV device. The prototype BBV device with aluminium foil and pencil lead as its anode and cathode produced the highest carotenoid and biodiesel component production from the two microalgae tested, according to the results of the first phase of the experiment. In the second portion of the study, Scenedesmus dimorphus and Chlorella vulgaris were identified as the two microalgae most capable of maintaining their growth throughout the experiment. The maximum current reading observed for C. vulgaris was 653 mV. High Performance Liquid Chromatography analysis showed four major carotenoid compounds found which were Neoxanthin, Cantaxanthin, Astaxanthin and 9-cis antheraxanthin, and the highest carotenoid producer was C. vulgaris which recorded at 1.73 μg/mL. C. vulgaris recorded as the most alkanes producer with 22 compounds detected and Heptacosane and Heneicosane as the two major biodiesel compounds found in the extracts. Evaluation of C. vulgaris data showed that it has enormous potential for microalgal biorefinery candidates. Further ongoing research and development efforts for C. vulgaris will improve the economic viability of microalgae-based industries and reduce reliance on depleted fossil fuels.

Various advanced wastewater treatment methods to remove microplastics and prevent transmission of SARS-CoV-2 to airborne microplastics

Microplastics (MPs) and SARS-CoV-2 interact due to their widespread presence in our environment and affect the virus' behaviour indoors and outdoors. Therefore, it is necessary to study the interaction between MPs and SARS-CoV-2. The environmental damage caused by MPs is increasing globally. Emerging pollutants may adversely affect organisms, especially sewage, posing a threat to human health, animal health, and the ecological system. A significant concern with MPs in the air is that they are a vital component of MPs in the other environmental compartments, such as water and soil, which may affect human health through ingesting or inhaling. This work introduces the fundamental knowledge of various methods in advanced water treatment, including membrane bioreactors, advanced oxidation processes, adsorption, etc., are highly effective in removing MPs; they can still serve as an entrance route due to their constantly being discharged into aquatic environments. Following that, an analysis of each process for MPs' removal and mitigation or prevention of SARS-CoV-2 contamination is discussed. Next, an airborne microplastic has been reported in urban areas, raising health concerns since aerosols are considered a possible route of SARS-CoV-2 disease transmission and bind to airborne MP surfaces. The MPs can be removed from wastewater through conventional treatment processes with physical processes such as screening, grit chambers, and pre-sedimentation.

1294 Online Education for Patients Undergoing Elective Orthopaedic Surgery During A Global Pandemic

Introduction

lective hip and knee joint replacement patients at the East Lancashire Hospitals NHS Trust (ELHT) are required to attend the ‘Hip and Knee Joint School’. This is an award-winning patient education programme. Pre-pandemic, it was a day at the hospital dedicated to introducing patients to the specifics of a hip and knee joint replacement surgery. This takes the patient from the process of anaesthesia to post-operative ward care.

Method

Due to the virulent transmission of COVID-19, strict social distancing rules have been implemented. Therefore, it was decided that converting the joint school into online videos would be the best medium for patient education. Various healthcare professionals contributed to the videos included orthopaedic surgeons, anaesthetists, specialist nurses, healthcare assistants, occupational therapists, and physiotherapists.

Results

Eleven videos were filmed, edited, and approved by the trust’s communications team. These included, ‘Introduction to the Joint School’, ‘You and your surgery’, ‘Leading up to your operation’, ‘Your Operation Journey’, ‘Introducing the Anaesthetist’ ‘Total Hip Replacement Surgery’, ‘Total Knee Replacement Surgery’, ‘Post-op Wound Care’, ‘Your Safe Discharge Home’, ‘FAQ’s’ and ‘COVID-19 Green Pathway’.

Conclusions

The global pandemic has driven innovation and novel ideas in medicine. We have seen similar changes in our trust with the online patient education videos being a prime example. This joint school was originally started in our trust, but now as it had been converted to videos, we believe that it can be modified and used across all trusts in the NHS.

P22: CONSERVATIVE MANAGEMENT OF NECK OF FEMUR FRACTURES

Introduction

According to NICE CG124, the gold standard of treatment for neck of femur (NOF) fractures is operative management on the day or day after admission. In practice, this is not always achievable depending on various factors, e.g. patient preference, clinical condition and theatre availability, with a further subset of patients undergoing conservative management.

Method

A retrospective analysis was performed on all NOF fractures managed non-operatively at a single centre from January 2017 to August 2019 by case notes analysis and review of radiographical images. Demographics, fracture type, pre-fracture mobility status, co-morbidities, mortality and Nottingham Hip Fracture Score (NHFS) are reported. Where applicable, our dataset is correlated with the National Hip Fracture Database for comparison.

Result

24 patients were included in the study period, with a mean age of 79.9 years (range 54-99 years) and male:female ratio of 0.85:1. The mean NHFS (n=18) was 5.7 (range 3-8) and at least 62.5% (n=15) were deemed unfit for surgery or arrested pre-operatively. Conservatively managed NOF fractures are associated with a 30-day mortality of 41.7% compared to the centre average of 8.2% and national average of 6.9% for all NOF fractures. Overall mortality within 1 year is 95.5% (n=22).

Conclusion

Our study confirms that the conservative management of NOF fractures is associated with high mortality, however it may be the only treatment option acceptable in patients who are limited by unfavourable clinical conditions. Therefore, the decision for conservative management in NOF fractures requires careful consideration with the need for an established decision-making pathway.

Take-home message

The conservative management of neck of femur fractures is associated with high mortality, therefore requires careful consideration with the need for an established decision-making pathway.

Notch Signaling Mediates Differentiation in Barrett's Esophagus and Promotes Progression to Adenocarcinoma

BACKGROUND & AIMS

Studies are needed to determine the mechanism by which Barrett's esophagus (BE) progresses to esophageal adenocarcinoma (EAC). Notch signaling maintains stem cells in the gastrointestinal tract and is dysregulated during carcinogenesis. We explored the relationship between Notch signaling and goblet cell maturation, a feature of BE, during EAC pathogenesis.

METHODS

We measured goblet cell density and levels of Notch messenger RNAs in BE tissues from 164 patients, with and without dysplasia or EAC, enrolled in a multicenter study. We analyzed the effects of conditional expression of an activated form of NOTCH2 (pL2.Lgr5.N2IC), conditional deletion of NOTCH2 (pL2.Lgr5.N2fl/fl), or loss of nuclear factor κB (NF-κB) (pL2.Lgr5.p65fl/fl), in Lgr5+ (progenitor) cells in L2-IL1B mice (which overexpress interleukin 1 beta in esophagus and squamous forestomach and are used as a model of BE). We collected esophageal and stomach tissues and performed histology, immunohistochemistry, flow cytometry, transcriptome, and real-time polymerase chain reaction analyses. Cardia and forestomach tissues from mice were cultured as organoids and incubated with inhibitors of Notch or NF-kB.

RESULTS

Progression of BE to EAC was associated with a significant reduction in goblet cell density comparing nondysplastic regions of tissues from patients; there was an inverse correlation between goblet cell density and levels of NOTCH3 and JAG2 messenger RNA. In mice, expression of the activated intracellular form of NOTCH2 in Lgr5+ cells reduced goblet-like cell maturation, increased crypt fission, and accelerated the development of tumors in the squamocolumnar junction. Mice with deletion of NOTCH2 from Lgr5+ cells had increased maturation of goblet-like cells, reduced crypt fission, and developed fewer tumors. Esophageal tissues from in pL2.Lgr5.N2IC mice had increased levels of RelA (which encodes the p65 unit of NF-κB) compared to tissues from L2-IL1B mice, and we found evidence of increased NF-κB activity in Lgr5+ cells. Esophageal tissues from pL2.Lgr5.p65fl/fl mice had lower inflammation and metaplasia scores than pL2.Lgr5.N2IC mice. In organoids derived from pL2-IL1B mice, the NF-κB inhibitor JSH-23 reduced cell survival and proliferation.

CONCLUSIONS

Notch signaling contributes to activation of NF-κB and regulates differentiation of gastric cardia progenitor cells in a mouse model of BE. In human esophageal tissues, progression of BE to EAC was associated with reduced goblet cell density and increased levels of Notch expression. Strategies to block this pathway might be developed to prevent EAC in patients with BE.

Comparative genomics study reveals Red Sea Bacillus with characteristics associated with potential microbial cell factories (MCFs)

Recent advancements in the use of microbial cells for scalable production of industrial enzymes encourage exploring new environments for efficient microbial cell factories (MCFs). Here, through a comparison study, ten newly sequenced Bacillus species, isolated from the Rabigh Harbor Lagoon on the Red Sea shoreline, were evaluated for their potential use as MCFs. Phylogenetic analysis of 40 representative genomes with phylogenetic relevance, including the ten Red Sea species, showed that the Red Sea species come from several colonization events and are not the result of a single colonization followed by speciation. Moreover, clustering reactions in reconstruct metabolic networks of these Bacillus species revealed that three metabolic clades do not fit the phylogenetic tree, a sign of convergent evolution of the metabolism of these species in response to special environmental adaptation. We further showed Red Sea strains Bacillus paralicheniformis (Bac48) and B. halosaccharovorans (Bac94) had twice as much secreted proteins than the model strain B. subtilis 168. Also, Bac94 was enriched with genes associated with the Tat and Sec protein secretion system and Bac48 has a hybrid PKS/NRPS cluster that is part of a horizontally transferred genomic region. These properties collectively hint towards the potential use of Red Sea Bacillus as efficient protein secreting microbial hosts, and that this characteristic of these strains may be a consequence of the unique ecological features of the isolation environment.

Downregulation of Friend Leukemia Integration 1 (FLI1) follows the stepwise progression to gastric adenocarcinoma

Gastric adenocarcinoma (GC) is a leading cause of cancer-related deaths worldwide. The transcription factor gene Friend Leukemia Integration 1 (FLI1) is methylated and downregulated in human GC tissues. Using human GC samples, we determined which cells downregulate FLI1, when FLI1 downregulation occurs, if FLI1 downregulation correlates with clinical-pathologic characteristics, and whether FLI1 plays a role in invasion and/or proliferation of cultured cells. We analyzed stomach tissues from 98 patients [8 normal mucosa, 8 intestinal metaplasia (IM), 7 dysplasia, 91 GC] by immunohistochemistry for FLI1. Epithelial cells from normal, IM, and low-grade dysplasia (LGD) showed strong nuclear FLI1 staining. GC epithelial cells showed significantly less nuclear FLI1 staining as compared to normal epithelium, IM and LGD (P=1.2×10^-5, P=1.4×10^-6 and P=0.006, respectively). FLI1 expression did not correlate with tumor stage or differentiation, but was associated with patient survival, depending on tumor differentiation. We tested the functional role of FLI1 by assaying proliferation and invasion in cultured GC cells. Lentiviral-transduced FLI1 overexpression in GC AGS cells inhibited invasion by 73.5% (P = 0.001) and proliferation by 31.5% (P = 0.002), as compared to controls. Our results support a combined role for FLI1 as a suppressor of invasiveness and proliferation in gastric adenocarcinoma, specifically in the transition from pre-cancer lesions and dysplasia to invasive adenocarcinoma, and suggest that FLI1 may be a prognostic biomarker of survival in gastric cancers.

Abstract 5532: Functional role of Friend Leukemia Integration-1 (FLI1) in gastric carcinogenesis

Gastric adenocarcinoma (GC) is the 5th most common cancer worldwide but is the 3rd leading cause of cancer death. FLI1 (Friend leukemia integration-1) is an ETS family transcription factor that regulates genes involved in proliferation and differentiation. FLI1 is implicated in tumorigenesis, such as in Ewing’s sarcoma where a translocation creates an EWS-FLI1 oncogenic fusion protein. However, few studies have examined the role of FLI1 in carcinomas. In human breast cancer, overexpression of FLI1 led to inhibition of apoptosis, thereby promoting survival and malignant potential. In functional studies in a murine breast cancer model, however, downregulation of FLI1 increased malignant potential. In human GCs, we recently reported that FLI1 expression is inversely correlated with its promoter CpG methylation of the FLI1.

To determine if decreased expression occurs in GC epithelial cells or background non-epithelial cells, we analyzed 91 human GC tumors by immunohistochemistry (IHC) for FLI1 and compared them to normal gastric mucosa and intestinal metaplasia (IM) using an IHC composite scoring system accounting for intensity and percentage of epithelial cells expressing FLI1. We found that FLI1 is strongly expressed in normal gastric glandular epithelium and in IM, and that decreased expression was seen in most human GCs (P < 1x10-17 vs normal, P < 1x10-26 vs IM). These findings suggest that FLI1 acts as a tumor suppressor gene in GC. To test this hypothesis, we used an invasion assay and the human GC cell lines NUGC3 and SNU638, which have little to no FLI1 expression, respectively. Cultured GC cells were transduced to overexpress FLI1 or control, along with an eGFP reporter from an IRES (Lv203, Genecopoeia). After selection by puromycin, these GC cells were plated in serum-free media in the upper chamber on a Matrigel coated 8µm pore opaque membrane. Complete media with 10% fetal calf serum was plated in the lower chamber. Images were obtained of the lower membrane with an inverted fluorescent microscope and cellSens imaging software. Overexpression of FLI1 significantly decreased invasion by NUGC3 cells at 24 hours (P = 0.013) but not at 48 hours (P = 0.268) as compared to control. Overexpression of FLI1 significantly decreased invasion by SNU638 cells at both 24 and 48 hours (P = 0.027 and 0.012, respectively) as compared to control. Since NUGC3 cells have low FLI1 expression, we knocked down FLI1 by using a FLI1 shRNA lentiviral system with mCherry from an IRES as a reporter (LvRU6MP, Genecopoeia). Using the same invasion assay, knockdown of FLI1 trended towards a significant increase in invasion as compared to control at 48 hrs (P = 0.14), but not at 24 hrs (P = 0.73).

In summary, the combined observations in human GC tissue samples and the functional analyses in GC cells support a tumor suppressor role for FLI1 in human GC and also suggest that FLI1 and/or its target genes may be involved in regulatory mechanisms driving invasive properties of GC.

Citation Format: Armando Del Portillo, Elena V. Komissarova, Anne Koehne de Gonzalez, Aqiba Bokhari, Helen Remotti, Jorge Sepulveda, Antonia Sepulveda. Functional role of Friend Leukemia Integration-1 (FLI1) in gastric carcinogenesis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5532. doi:10.1158/1538-7445.AM2017-5532

Cytomorphology of Recurrent Osseous Extracranial Meningioma of Right Pubic Ramus:: Report of a Case and Literature Review

Meningiomas are well-recognized neoplasms of the central nervous system. Primary extracranial meningiomas (ECMs) are extremely rare and arise in various anatomic sites. We present a 56-year-old female with 13-year history of primary grade I meningothelial meningioma of right pubic symphysis, orthotopic heart transplant, and right total hip arthroplasty, who presented with progressive right hip pain for 3 weeks. Primary intracranial, intraspinal and other tumors were excluded. Imaging revealed a destructive lytic lesion at right superior and inferior pubic rami and body, associated with extensive bone destruction and soft tissue mass. Touch imprint (TI) cytology of computed tomography (CT)-guided core biopsy from the right pubic ramus (PRA) lesion showed a spindle cell neoplasm, with classical syncytial, lobular, and whorling cellular arrangement, composed of spindle, oval or round nuclei with occasional pseudoinclusions, consistent with known history of osseous meningioma. Tumor was further characterized by histopathology as grade 1 meningioma with meningothelial features. To our knowledge, primary osseous ECM arising specifically at the PRA has not been reported previously. ECM at this site may pose a diagnostic challenge for cytologists as its features may resemble other more commonly observed lesions. Accurate diagnosis requires awareness of occurrence of ECM at PRA and recognition of its characteristic cytomorphology. TI cytological features of our case are presented and previously described cytology of ECMs and diagnostic pitfalls are reviewed. Diagn. Cytopathol. 2016;44:618-622. © 2016 Wiley Periodicals, Inc.

Minimally invasive use of coloured composite resin in aesthetic restoration of periodontially involved teeth: Case report

Gingival recession causes not only aesthetic problems, but problems with oral hygiene, plaque accumulation, speech, and tooth sensitivity. Replacing the missing gingival tissue with composite resin, when indicated, can be a time- and cost-effective solution. Here we report the case of a 25-year-old female who presented with generalized gingival recession. Black triangles were present between the maxillary and mandibular anterior teeth due to loss of interdental tissues, caused by recent periodontal surgery. She also had slightly malposed maxillary anterior teeth. The patient elected to replace gingival tissue with pink composite resin and to alter the midline with composite resin veneers. The first treatment phase involved placement of pink gingival composite to restore the appearance of interdental papilla to her upper (16, 15, 14, 13, 12, 11, 21, 22, 23, and 24) and lower (34, 33, 32, 31, 41, 42, 43, and 44) teeth. Phase two was to place direct composite resin bonded veneers on her upper (16, 15, 14, 13, 12, 11, 21, 22, 23, and 24) teeth to alter the midline and achieve desired colour. The third treatment phase was to level the lower incisal edge shape by enameloplasty (31, 32, 41, and 42) to produce a more youthful and attractive smile. This case report and brief review attempt to describe the clinical obstacles and the current treatment options along with a suggested protocol. Use of contemporary materials such as gingival coloured composite to restore lost gingival tissue and improve aesthetics can be a simple and cost-effective way to manage patients affected by generalized aggressive periodontitis (AgP).

Intraventricular hemorrhage induces deposition of proteoglycans in premature rabbits, but their in vivo degradation with chondroitinase does not restore myelination, ventricle size and neurological recovery

Intraventricular hemorrhage (IVH) results in white matter injury and hydrocephalus in premature infants. Chondroitin sulfate proteoglycans (CSPGs)-neuorcan, brevican, versican, aggrecan and phosphacan-are unregulated in the extracellular matrix after brain injury, and their degradation enhances plasticity of the brain. Therefore, we hypothesized that CSPG levels were elevated in the forebrain of premature infants with IVH and that in vivo degradation of CSPGs would enhance maturation of oligodendrocyte, augment myelination, promote neurological recovery, and minimize hydrocephalus. We found that levels of neurocan, brevican, aggrecan, phosphacan, and versican were elevated, whereas NG2 expression was reduced in premature rabbit pups and human infants with IVH compared to controls. Intracerebroventricular chondroitinase ABC (ChABC) reduced the expression of neuorcan, brevican, versican and aggrecan, but not NG2. However, ChABC treatment did not enhance maturation of oligodendrocytes, myelination, or neurological recovery in the pups with IVH. Moreover, ChABC did not reduce gliosis or ventriculomegaly. Our results demonstrate that IVH induces distinct changes in the components of CSPGs, and that reversing these changes by in vivo ChABC treatment neither promotes clinical recovery, myelination, nor reduces ventriculomegaly in preterm rabbit pups.

HIV and other sexually transmitted infections among men, transgenders and women selling sex in two cities in Pakistan: a cross-sectional prevalence survey

OBJECTIVES

The extent and possibilities of spread of the HIV epidemic are not fully understood in Pakistan. A survey was conducted among men, women and transgender populations selling sex in Rawalpindi (Punjab) and Abbottabad (North West Frontier Province) in order to inform evidence-based programme planning.

METHODS

A cross-sectional survey was performed with participants recruited through respondent-driven sampling. Male and transgender sex workers were analysed in three gender groups; women were analysed as one group. Behavioural surveys were conducted and clinical specimens collected. Laboratory tests looked for evidence of acute infection (gonorrhoea, Chlamydia, syphilis, Trichomonas) and infection over the lifetime (HIV, herpes simplex virus-2, syphilis). Predictors of infection were explored using univariable and multivariable logistic regression.

RESULTS

The prevalence of HIV was low in 917 male and transgender sex workers and absent in 533 female sex workers in the study. High levels of current sexually transmitted infections were found, predominantly among transgender sex workers. Risk behaviours were common and knowledge of HIV was extremely low. Multivariable analysis found a large number of factors associated with higher levels of infection, including experience of forced first sex. Protection against risk was low, but those sex workers who reported using condoms at last sex had lower rates of infection.

CONCLUSIONS

The HIV epidemic is currently in its early stages among people who sell sex, but there may be potential for a much greater spread given the levels of other sexually transmitted infections found and the concomitant low levels of both protective knowledge and risk-reducing behaviours. Action is needed now to avert an epidemic. Framing interventions by upholding the recognition and protection of human rights is vital.

Asian earthquake: report from the first volunteer British hospital team in Pakistan

At 8:52 am on 8 October 2005 a massive earthquake wracked northern Pakistan and Kashmir. Various teams were sent to Islamabad and the disaster region from the UK. We discuss the types of injury patterns seen and recommend that a central register of volunteers should be created to deal with similar situations in the future.

Management of unanticipated difficult intubation: a survey of current practice in the Oxford region

BACKGROUND AND OBJECTIVE

Unanticipated difficulty in tracheal intubation in an anaesthetized patient has always been a cause of concern to anaesthesiologists. This difficulty may lead to morbidity and mortality. This survey was carried out to determine the technique commonly favoured in centres in the Oxford region in the UK for the management of unanticipated difficult intubation.

METHODS

We conducted a clinical scenario-based questionnaire survey of 181 anaesthesiologists in the Oxford region. In this scenario, difficulty in endotracheal intubation is recognized only after induction of anaesthesia. A number of options were available to deal with this situation. We used this scenario as a tool to gain insight into the training and the training needs of anaesthesiologists at various levels of training.

RESULTS

Of the 181 questionnaires sent, we received 143 (79%) completed replies. The vast majority (141/143 (99%)) of anaesthesiologists would use a gum-elastic bougie together with head and neck positioning and optimal external laryngeal manipulation to gain the best attempt at intubation. If intubation still failed, overall 129/143 (90%) had a back-up plan, while 14/143 (10%) had no plan. Flexible fibreoptic techniques were more commonly planned by 92/143 (64%) anaesthesiologists compared to blind techniques which were less commonly planned by 37/143 (26%) anaesthesiologists. Differences in choice of technique among anaesthesiologists in teaching and district general hospitals were not significant (P = 0.87). Overall, trainees were less likely to choose fibreoptic techniques compared to consultants (P = 0.0009) and would use blind techniques or ask a more experienced colleague to take over. The main reason for the choice was previous experience with the technique.

CONCLUSIONS

Although fibreopric techniques were most commonly planned, these were less often chosen by trainees than consultants due to lack of experience/training, while unavailability of intubating laryngeal mask airway (Intavent) was an additional issue precluding its use as an adjunct to intubation.

Anorectal melanoma--3 case reports and a review of the literature

Anorectal melanoma is an uncommon disease. Histologically, the tumor may mimic adenocarcinomas, small cell carcinomas, and sarcomas; grossly, the lesion often mimics hemorrhoids. We report 3 cases of anorectal melanoma: a 40-year-old woman with anorectal melanoma with local recurrence after an abdominoperineal resection (APR); a 30-year-old woman with anorectal melanoma and multiple liver metastases returning with multiple masses in the rectum and 2 nodules above and below the left clavicle after receiving chemotherapy; and a 62-year-old woman with inguinal node metastases. The histologic findings in all 3 cases revealed malignant tumor composed of atypical melanocytes diagnosed as malignant melanoma of the rectum. In the first case, APR with pararectal lymphadenectomy was performed. Histopathology revealed nodal metastasis. The patient was noncompliant with chemotherapy and died after several months. In the second case, chemotherapeutic treatment was begun. Seven months after receiving chemotherapy, the patient returned with multiple metastases. The final case was lost to follow-up after referral to an oncologist. Anorectal melanoma is highly aggressive and unresponsive to both radical surgery and local control. Although supplemental therapy may improve quality of life and prolong survival, the 5-year survival rate is 10% with a mean survival time of 15 to 25 months. In the 3 cases presented, metastatic disease was present at the time of diagnosis. At this stage, APR with lymphadenectomy followed by some form of adjuvant therapy is our recommended treatment.

Subglottic ductal cysts associated with complete tracheal ring deformity: coexistence of two rare airway abnormalities with fatal outcome

Subglottic cysts are rare and may cause airway obstruction. Most cases are acquired secondary to endotracheal intubation, even short-term, particularly in the premature neonate. Complete tracheal rings are rare anomalies associated with tracheal stenosis. To our knowledge, the two have not been reported coexisting. A 16-month-old ex-premature boy was found unresponsive, with his tracheostomy tube dislodged. Tracheomalacia, subglottic stenosis, and a laryngeal cyst had been diagnosed shortly after birth, and the cyst was surgically treated at that time. At autopsy, a complete tracheal ring was noted in the subglottic region, above the tracheostomy site, and the tracheal diameter was markedly decreased in this area. In addition, multiloculated cysts were present at that level, arising from both anterolateral tracheal walls. These completely occluded the airway. To our knowledge, this is the first case of a combination of tracheal ring anomaly and subglottic cysts. Pediatric pathologists must be aware of iatrogenic lesions associated with care of the premature neonate, particularly as the age of viability continues to decrease.

Cystic struma ovarii presenting with ascites and an elevated CA-125 level. A case report

BACKGROUND

Struma ovarii is a monodermal teratoma that usually presents as a solid pelvic mass. Occasionally the lesions are cystic. Rare cases present with ascites or pseudo-Meigs' syndrome. The association of a cystic struma ovarii with ascites and an elevated CA-125 level is exceptionally rare.

CASE

A 51-year-old woman presented with ascites and a cystic pelvic mass. There was marked elevation of her CA-125 level. The clinical impression was ovarian carcinoma. Frozen section revealed a multicystic struma ovarii.

CONCLUSION

Struma ovarii can mimic ovarian carcinoma clinically, particularly if cystic and associated with ascites and an elevated CA-125 level.

Effects on toes from prenatal exposure to anticonvulsants

BACKGROUND

Changes in the distal phalanges of the fingers, including coned epiphyses and hypoplasia of the phalanges, are recognized teratogenic effects of the anticonvulsant drugs phenytoin and phenobarbital. We hypothesized that the frequency of these changes would also be increased in the toes of children exposed to these drugs in comparison to unexposed children.

METHODS

We report on the findings in an analysis of radiographs of the feet of 63 children exposed in utero to either phenytoin alone, phenobarbital alone or both drugs and 56 unexposed comparison children.

RESULTS

Only subtle changes were identified. The frequency of coned epiphyses and hypoplasia of phalanges of the toes was the same in both the anticonvulsant and unexposed children. Among the anticonvulsant-exposed children, however, there was a strong association between the presence of coned epiphyses in the feet and in the hands: all five children with coned epiphyses in the hands, as described previously in the same individuals by Lu et al. ([2000] Teratology 61:277-283) had coned epiphyses in their feet (P = 0.0012). Measurements showed a shortening of metatarsals in all three treatment groups, but this was significant only in the phenytoin monotherapy-exposed children.

CONCLUSIONS

Subtle changes are present in the phalanges and metatarsals of the feet of anticonvulsant-exposed children, but the overall frequency is much less than occurred in the hands of the same children. We conclude that the presence of either coned epiphyses or hypoplasia of the phalanges of the toes cannot be considered a distinctive feature of the teratogenicity of the anticonvulsant drugs phenytoin and phenobarbital.

Effect of prenatal exposure to anticonvulsant drugs on dermal ridge patterns of fingers

BACKGROUND

An altered frequency of specific dermal ridge patterns on fingertips, such as an increased number of arches, has been observed in children exposed in utero to anticonvulsants and other teratogens. Asymmetry of the distribution of dermal ridge patterns has been attributed to environmental exposures and genetic factors.

METHODS

We evaluated all of the dermal ridge patterns of 66 children who had been exposed to either the anticonvulsant phenytoin alone or phenytoin and phenobarbital. We determined the frequency of each pattern, concordance between the fingers on the left and right hands, sex differences and total ridge counts in the drug-exposed children and compared them to the findings in 716 unexposed comparison children. The frequency of each pattern was established in comparison to the most common type of pattern (ulnar loop), which showed that there were alterations in the frequency of arches, radial loops and whorls on specific fingers.

RESULTS

Eight (12.1%) of 66 children had three or more arch patterns, with all but one having been exposed to phenytoin and phenobarbital. Only one of these eight children was considered by the masked examiner to have fingernail hypoplasia. There was no evidence of asymmetry in the anticonvulsant-exposed children. There were minor differences in the distribution of total ridge count.

CONCLUSIONS

Subtle differences in several dermal ridge patterns, not just arch patterns, were present in anticonvulsant-exposed children, primarily in those exposed to polytherapy: phenytoin and phenobarbital.

Anaesthesia for assisted conception: a survey of UK practice

A telephone survey was undertaken of all UK centres (total 70) licensed for performing in vitro fertilization (IVF) and gamete intra-fallopian transfer (GIFT) by the Human Fertilisation and Embryology Authority (HFEA). The survey was carried out during the months of November and December 1997. Thirty-seven (52.1%) centres were in the NHS sector and 33 (47.8%) in the private sector. A response was available from 60 (84%) centres. A standard questionnaire was used which requested information about the procedures carried out, anaesthetic technique and pharmacological agents used. Forty-seven centres carried out IVF, two centres GIFT and 11 centres both. Out of 58 centres carrying out IVF, sedation was used in 28, general anaesthesia in 17, sedation combined with regional anaesthesia in seven and regional anaesthesia in one. Five centres gave a choice. Out of 22 centres using general anaesthesia for IVF, 12 used inhalational agents (isoflurane eight, enflurane four, sevoflurane two), eight used total intravenous anaesthesia (TIVA) with propofol and two centres inhalational agents or TIVA. Propofol was the induction agent in all but two centres. For IVF under sedation, 18 centres used midazolam, five used diazepam, three used opioids, one used entonox and the remaining ones a combination. When sedation was combined with regional anaesthesia, four centres used midazolam, two used propofol, one used midazolam with propofol, one used opioids and one used entonox. The regional technique in the 11 centres was either paracervical block with lignocaine (eight) or subarachnoid block with bupivacaine (three). Systemic analgesia was secured with fentanyl (22), pethidine (16), alfentanil (15), diclofenac (14), piroxicam (two), ketorolac (one) and ibuprofen (one). Five centres did not use any opioids; 40 centres did not use any nonsteroidal agents (NSAIDs). Out of the 13 centres that carried out GIFT, 12 used general anaesthesia while the thirteenth gave the patient a choice between general or regional anaesthesia. 11 centres used inhalational agents (isoflurane nine, enflurane two) while two used TIVA with propofol; propofol was the induction agent used in six centres while thiopentone was used in five. The range of analgesics was wide--fentanyl in six centres, alfentanil in three, morphine in two, diclofenac in five and ketorolac in one. Two centres did not use any opioids and seven centres did not use an NSAID. The only agreement at present appears to be that halothane is an unwise choice for IVF. No other technique has yet been proven to be either advantageous or detrimental.

Essential role for dlg in synaptic clustering of Shaker K+ channels in vivo

The assemblage of specific ion channels and receptors at synaptic sites is crucial for signaling between pre- and postsynaptic cells. However, the mechanisms by which proteins are targeted to and clustered at synapses are poorly understood. Here we show that the product of the Drosophila discs-large gene, DLG, is colocalized with Shaker K+ channels, which are clustered at glutamatergic synapses at the larval neuromuscular junction. In heterologous cells, DLG can cluster Shaker-type K+ channels, and, in the yeast two-hybrid system, the DLG PDZ1-2 domains bind directly to the C-terminal tail of Shaker proteins. We also demonstrate that DLG-Shaker interactions are required in vivo for Shaker clustering at the neuromuscular junction. Synaptic clustering of Shaker channels is abolished not only by mutations in dlg but also by a mutation in Shaker that deletes its C-terminal DLG binding motif. Analyses of various dlg mutant alleles suggest that channel clustering and synaptic targeting functions depend on distinct DLG domains. These studies demonstrate for the first time that DLG plays an important role in synaptic organization in vivo that correlates with its ability to bind directly to specific membrane proteins of the synapse.