Microbial communities colonising plastics during transition from the wastewater treatment plant to marine waters

BACKGROUND

Plastics pollution and antimicrobial resistance (AMR) are two major environmental threats, but potential connections between plastic associated biofilms, the 'plastisphere', and dissemination of AMR genes are not well explored.

RESULTS

We conducted mesocosm experiments tracking microbial community changes on plastic surfaces transitioning from wastewater effluent to marine environments over 16 weeks. Commonly used plastics, polypropylene (PP), high density polyethylene (HDPE), low density polyethylene (LDPE) and polyethylene terephthalate (PET) incubated in wastewater effluent, river water, estuarine water, and in the seawater for 16 weeks, were analysed via 16S rRNA gene amplicon and shotgun metagenome sequencing. Within one week, plastic-colonizing communities shifted from wastewater effluent-associated microorganisms to marine taxa, some members of which (e.g. Oleibacter-Thalassolituus and Sphingomonas spp., on PET, Alcanivoracaceae on PET and PP, or Oleiphilaceae, on all polymers), were selectively enriched from levels undetectable in the starting communities. Remarkably, microbial biofilms were also susceptible to parasitism, with Saprospiraceae feeding on biofilms at late colonisation stages (from week 6 onwards), while Bdellovibrionaceae were prominently present on HDPE from week 2 and LDPE from day 1. Relative AMR gene abundance declined over time, and plastics did not become enriched for key AMR genes after wastewater exposure.

CONCLUSION

Although some resistance genes occurred during the mesocosm transition on plastic substrata, those originated from the seawater organisms. Overall, plastic surfaces incubated in wastewater did not act as hotspots for AMR proliferation in simulated marine environments.

Harnessing extremophilic carboxylesterases for applications in polyester depolymerisation and plastic waste recycling

The steady growth in industrial production of synthetic plastics and their limited recycling have resulted in severe environmental pollution and contribute to global warming and oil depletion. Currently, there is an urgent need to develop efficient plastic recycling technologies to prevent further environmental pollution and recover chemical feedstocks for polymer re-synthesis and upcycling in a circular economy. Enzymatic depolymerization of synthetic polyesters by microbial carboxylesterases provides an attractive addition to existing mechanical and chemical recycling technologies due to enzyme specificity, low energy consumption, and mild reaction conditions. Carboxylesterases constitute a diverse group of serine-dependent hydrolases catalysing the cleavage and formation of ester bonds. However, the stability and hydrolytic activity of identified natural esterases towards synthetic polyesters are usually insufficient for applications in industrial polyester recycling. This necessitates further efforts on the discovery of robust enzymes, as well as protein engineering of natural enzymes for enhanced activity and stability. In this essay, we discuss the current knowledge of microbial carboxylesterases that degrade polyesters (polyesterases) with focus on polyethylene terephthalate (PET), which is one of the five major synthetic polymers. Then, we briefly review the recent progress in the discovery and protein engineering of microbial polyesterases, as well as developing enzyme cocktails and secreted protein expression for applications in the depolymerisation of polyester blends and mixed plastics. Future research aimed at the discovery of novel polyesterases from extreme environments and protein engineering for improved performance will aid developing efficient polyester recycling technologies for the circular plastics economy.

Increasing concentration of pure micro- and macro-LDPE and PP plastic negatively affect crop biomass, nutrient cycling, and microbial biomass

Over the last 50 years, the intense use of agricultural plastic in the form of mulch films has led to an accumulation of plastic in soil, creating a legacy of plastic in agricultural fields. Plastic often contains additives, however it is still largely unknown how these compounds affect soil properties, potentially influencing or masking effects of the plastic itself. Therefore, the aim of this study was to investigate the effects of pure plastics of varying sizes and concentrations, to improve our understanding of plastic-only interactions within soil-plant mesocosms. Maize (Zea mays L.) was grown over eight weeks following the addition of micro and macro low-density polyethylene and polypropylene at increasing concentrations (equivalent to 1, 10, 25, and 50 years mulch film use) and the effects of plastic on key soil and plant properties were measured. We found the effect of both macro and microplastic on soil and plant health is negligible in the short-term (1 to <10 years). However, ≥ 10 years of plastic application for both plastic types and sizes resulted in a clear negative effect on plant growth and microbial biomass. This study provides vital insight into the effect of both macro and microplastics on soil and plant properties.

High Representation of Archaea Across All Depths in Oxic and Low-pH Sediment Layers Underlying an Acidic Stream

Parys Mountain or Mynydd Parys (Isle of Anglesey, United Kingdom) is a mine-impacted environment, which accommodates a variety of acidophilic organisms. Our previous research of water and sediments from one of the surface acidic streams showed a high proportion of archaea in the total microbial community. To understand the spatial distribution of archaea, we sampled cores (0-20 cm) of sediment and conducted chemical analyses and taxonomic profiling of microbiomes using 16S rRNA gene amplicon sequencing in different core layers. The taxonomic affiliation of sequencing reads indicated that archaea represented between 6.2 and 54% of the microbial community at all sediment depths. Majority of archaea were associated with the order Thermoplasmatales, with the most abundant group of sequences being clustered closely with the phylotype B_DKE, followed by "E-plasma," "A-plasma," other yet uncultured Thermoplasmatales with Ferroplasma and Cuniculiplasma spp. represented in minor proportions. Thermoplasmatales were found at all depths and in the whole range of chemical conditions with their abundance correlating with sediment Fe, As, Cr, and Mn contents. The bacterial microbiome component was largely composed in all layers of sediment by members of the phyla Proteobacteria, Actinobacteria, Nitrospirae, Firmicutes, uncultured Chloroflexi (AD3 group), and Acidobacteria. This study has revealed a high abundance of Thermoplasmatales in acid mine drainage-affected sediment layers and pointed at these organisms being the main contributors to carbon, and probably to iron and sulfur cycles in this ecosystem.

Altered subcortical emotional salience processing differentiates Parkinson's patients with and without psychotic symptoms

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Emotional salience processing differentiates PD patients with and without psychosis.

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Enhanced striatal, hippocampal and midbrain responses in PD patients with psychosis.

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Indication for ‘jumping to conclusions’ bias in the same PD patients with psychosis.

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Aberrant top-down and salience processing associated with PD psychosis.

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Similar deficits as proposed in ‘aberrant salience hypothesis’ of schizophrenia.

Objective

Current research does not provide a clear explanation for why some patients with Parkinson’s Disease (PD) develop psychotic symptoms. The ‘aberrant salience hypothesis’ of psychosis has been influential and proposes that dopaminergic dysregulation leads to inappropriate attribution of salience to irrelevant/non-informative stimuli, facilitating the formation of hallucinations and delusions. The aim of this study is to investigate whether non-motivational salience is altered in PD patients and possibly linked to the development of psychotic symptoms.

Methods

We investigated salience processing in 14 PD patients with psychotic symptoms, 23 PD patients without psychotic symptoms and 19 healthy controls. All patients were on dopaminergic medication for their PD. We examined emotional salience using a visual oddball fMRI paradigm that has been used to investigate early stages of schizophrenia spectrum psychosis, controlling for resting cerebral blood flow as assessed with arterial spin labelling fMRI.

Results

We found significant differences between patient groups in brain responses to emotional salience. PD patients with psychotic symptoms had enhanced brain responses in the striatum, dopaminergic midbrain, hippocampus and amygdala compared to patients without psychotic symptoms. PD patients with psychotic symptoms showed significant correlations between the levels of dopaminergic drugs they were taking and BOLD signalling, as well as psychotic symptom scores.

Conclusion

Our study suggests that enhanced signalling in the striatum, dopaminergic midbrain, the hippocampus and amygdala is associated with the development of psychotic symptoms in PD, in line with that proposed in the ‘aberrant salience hypothesis’ of psychosis in schizophrenia.

Successful Treatment of Tuberculosis in Renal Transplant Recipients1

Tuberculosis is a rare and usually fatal complication of renal transplantation. From 82 transplants in seven years, 4 cases of tuberculosis are reported. All have been treated successfully, with no fatalities or deterioration in renal function.

Neuroinflammatory and morphological changes in late-life depression: the NIMROD study

We studied neuroinflammation in individuals with late-life depression, as a risk factor for dementia, using [¹¹C]PK11195 positron emission tomography (PET). Five older participants with major depression and 13 controls underwent PET and multimodal 3T magnetic resonance imaging (MRI), with blood taken to measure C-reactive protein (CRP). We found significantly higher CRP levels in those with late-life depression and raised [¹¹C]PK11195 binding compared with controls in brain regions associated with depression, including subgenual anterior cingulate cortex, and significant hippocampal subfield atrophy in cornu ammonis 1 and subiculum. Our findings suggest neuroinflammation requires further investigation in late-life depression, both as a possible aetiological factor and a potential therapeutic target.

Delayed Pneumothorax: A Complication of Subclavian Vein Catheterization

Subclavian catheterization is a reliable, well-described technique of central venous access for a variety of indications. Significant complications are associated with the procedure. Detection of the majority of complications is afforded by the postinsertion chest x-ray. Delayed pneumothorax, a relatively unrecognized complication of subclavian catheterization, is caused by a slow pleural air leak which appears to be associated with the "difficult" insertion as illustrated by three case reports. A repeat or "delayed" chest roentgenogram should be considered in the following situations: Difficult subclavian insertions requiring multiple attempts. Suspicion of pleural injury such as aspiration of air during insertion or subcutaneous emphysema with a normal postinsertion chest x-ray. The presence of another major complication. If the patient complains of persistent pleuritic or back pain after insertion. Preoperatively after previous difficult insertion of a central venous line. Postoperatively when a subclavian catheter is inserted intraoperatively.

Development of a Combined microPET®-MR System

As evidenced by the success of PET-CT, there are many benefits from combining imaging modalities into a single scanner. The combination of PET and MR offers potential advantages over PET-CT, including improved soft tissue contrast, access to the multiplicity of contrast mechanisms available to MR, simultaneous imaging and fast MR sequences for motion correction. In addition, PET-MR is more suitable than PET-CT for cancer screening due to the elimination of the radiation dose from CT.

A key issue associated with combining PET and MR is the fact that the performance of the photomultiplier tubes (PMTs) used in conventional PET detectors is degraded in the magnetic field required for MR. Two approaches have been adopted to circumvent that issue: retention of conventional, magnetic field-sensitive PMT-based PET detectors by modification of other features of the MR or PET system, or the use of new, magnetic field-insensitive devices in the PET detectors including avalanche photo-diodes (APDs) and silicon photomultipliers (SiPMs).

Taking the former approach, we are assembling a modified microPET® Focus 120 within a gap in a novel, 1T superconducting magnet. The PMTs are located in a low magnetic field (~30mT) through a combination of magnet design and the use of fiber optic ‘bundles’.

Two main features of the modified PET system have been tested, namely the effect of using long fiber optic bundles in the PET detector, and the impact of magnetic field upon the performance of the position sensitive PMTs.

The design of a modified microPET®-MR system for small animal imaging is completed, and assembly and testing is underway.

Registration accuracy for VBM studies varies according to region and degenerative disease grouping

Voxel-based morphometry studies are frequently cited as having the advantage of being objective compared to region-of-interest methods. This statement assumes, however, that all regions are treated equally both in controls and diseased cohorts. This study aimed to test whether this statement is correct by analyzing fiducial landmarks in controls, Alzheimer's disease (as a model of mild generalized atrophy model); Frontotemporal Dementia (focal atrophy model) and Semantic Dementia (extreme focal atrophy model). Standard SPM5 and DARTEL were evaluated using either raw or skull-stripped/bias corrected scans. The results indicated that with all methods there was variability in the degree of misregistration across regions and that there was a disease grouping interaction-most severely in the extreme focal atrophy model (Semantic Dementia). Preprocessing improved VBM outputs both with standard SPM and DARTEL. In the latter case, this occurred to an extreme degree-DARTEL using raw data was grossly insensitive to a ground truth (manually verified hippocampal atrophy in AD) whereas DARTEL after preprocessing yielded excellent results with respect to this yardstick.

Analysis of acute traumatic axonal injury using diffusion tensor imaging

Traumatic axonal injury (TAI) contributes significantly to mortality and morbidity following traumatic brain injury (TBI), but is poorly characterized by conventional imaging techniques. Diffusion tensor imaging (DTI) may provide better detection as well as insights into the mechanisms of white matter injury. DTI data from 33 patients with moderate-to-severe TBI, acquired at a median of 32 h postinjury, were compared with data from 28 age-matched controls. The global burden of whole brain white matter injury (GB(WMI)) was quantified by measuring the proportion of voxels that lay below a critical fractional anisotropy (FA) threshold, identified from control data. Mechanisms of change in FA maps were explored using an Eigenvalue analysis of the diffusion tensor. When compared with controls, patients showed significantly reduced mean FA (p < 0.001) and increased apparent diffusion coefficient (ADC; p = 0.017). GB(WMI) was significantly greater in patients than in controls (p < 0.01), but did not distinguish patients with obvious white matter lesions seen on structural imaging. It predicted classification of DTI images as head injury with a high degree of accuracy. Eigenvalue analysis showed that reductions in FA were predominantly the result of increases in radial diffusivity (p < 0.001). DTI may help quantify the overall burden of white matter injury in TBI and provide insights into underlying pathophysiology. Eigenvalue analysis suggests that the early imaging changes seen in white matter are consistent with axonal swelling rather than axonal truncation. This technique holds promise for examining disease progression, and may help define therapeutic windows for the treatment of diffuse brain injury.

Atrophy patterns in histologic vs clinical groupings of frontotemporal lobar degeneration

OBJECTIVE

Predictable patterns of atrophy are associated with the clinical subtypes of frontotemporal dementia (FTD): behavioral variant (bvFTD), semantic dementia (SEMD), and progressive nonfluent aphasia (PNFA). Some studies of pathologic subtypes have also suggested specific atrophy patterns; however, results are inconsistent. Our aim was to test the hypothesis that clinical, but not pathologic, classification (FTD with ubiquitin inclusions [FTD-U] and FTD with tau inclusions [FTD-T]) is associated with predictable patterns of regional atrophy.

METHODS

Magnetic resonance scans of nine FTD-U and six FTD-T patients (histologically confirmed) were compared with 25 controls using voxel-based morphometry (VBM). Analyses were conducted with the patient group classified according to histologic or clinical variant. Additionally, three Alzheimer pathology patients who had the syndrome of SEMD in life (FTD-A) were analyzed.

RESULTS

The VBM studies in clinical variants confirmed established patterns of atrophy (SEMD, rostral temporal; bvFTD, mesial frontal; PNFA, left insula). FTD-U and FTD-T VBM results were very similar, showing severe atrophy in the temporal poles, mesial frontal lobe, and insulae. A conjunction analysis confirmed this similarity. Subgroup analysis found that SEMD associated with either FTD-T or FTD-U was associated with similar rostral temporal atrophy; however, FTD-A had a qualitatively different pattern of left hippocampal atrophy.

CONCLUSIONS

While there is predictable atrophy for clinical variants of frontotemporal dementia (FTD), histologic FTD variants show no noticeable differences. Reports of specific atrophy profiles are likely the result of idiosyncrasies in small groups. Semantic dementia associated with Alzheimer pathology, however, presented a distinct atrophy pattern.

Voxel-based morphometry in the R6/2 transgenic mouse reveals differences between genotypes not seen with manual 2D morphometry

The R6/2 mouse is the most common mouse model used for Huntington's disease (HD), a fatal, inherited neurodegenerative CAG disorder characterized by marked brain atrophy. We scanned 47 R6/2 transgenic and 42 wildtype (WT) ex vivo mouse brains at 18 weeks of age using high resolution, three-dimensional magnetic resonance imaging (MRI) for automated voxel-based morphometry (VBM) analysis. We found differences between genotypes in specific brain structures. Many of these changes were bilateral and were found in regions known to be involved in the behavioral deficits present in both R6/2 mice and HD patients. In particular, changes were evident in the basal ganglia, hippocampus, cortex and hypothalamus. In the striatum, changes were heterogenous and reminiscent of striosomal distribution. Changes were also seen in the cerebellum, as might be expected in a mouse carrying a repeat length typical of juvenile onset HD. Many of these changes were not detected by manual 2D morphometry from the same MR images. These data indicate that VBM will be a valuable technique for in vivo measurement of developing pathology in HD transgenic mice, and may be particularly useful for correlating histologically undetectable changes with behavioral deficits.

Imaging of cerebral blood flow and metabolism in brain injury in the ICU

The heterogeneity of the initial insult and subsequent pathophysiology has made both the study of human head injury and design of randomised controlled trials exceptionally difficult. The combination of multimodality bedside monitoring and functional brain imaging positron emission tomography (PET) and magnetic resonance (MR), incorporated within a Neurosciences Critical Care Unit, provides the resource required to study critically ill patients after brain injury from initial ictus through recovery from coma and rehabilitation to final outcome. Methods to define cerebral ischemia in the context of altered cerebral oxidative metabolism have been developed, traditional therapies for intracranial hypertension re-evaluated and bedside monitors cross-validated. New modelling and analytical approaches have been developed.

Diffusion tensor imaging in chronic head injury survivors: correlations with learning and memory indices

Diffusion tensor imaging (DTI) provides a unique insight into the cellular integrity of the brain. While conventional magnetic resonance imaging underestimates the extent of pathology following closed head injury, diffusion-weighted imaging has been shown to more accurately delineate the extent of cerebral damage. There have only been a few case studies of DTI in chronic head injury survivors. This study used DTI to investigate changes in anisotropy and diffusivity in survivors of head injury at least 6 months after their injury. The relationship between cognition and diffusion abnormality was also investigated. The voxel-based analysis revealed significant bilateral decreases in anisotropy, in major white matter tracts and association fibers in the temporal, frontal, parietal and occipital lobes. Statistically significant increases in diffusivity were also found in widespread areas of the cortex. A significant positive correlation was found between diffusivity and impairment of learning and memory in the left posterior cingulate, left hippocampal formation and left temporal, frontal and occipital cortex. The common pattern of abnormality despite heterogeneous injury mechanism and lesion location in the group suggests that these cellular changes reflect secondary insults. The importance of diffusion abnormalities in head injury outcome is emphasized by the significant correlation between a learning and memory index and diffusivity in areas known to subserve this cognitive function.

Physiological thresholds for irreversible tissue damage in contusional regions following traumatic brain injury

Cerebral ischaemia appears to be an important mechanism of secondary neuronal injury in traumatic brain injury (TBI) and is an important predictor of outcome. To date, the thresholds of cerebral blood flow (CBF) and cerebral oxygen utilization (CMRO(2)) for irreversible tissue damage used in TBI studies have been adopted from experimental and clinical ischaemic stroke studies. Identification of irreversibly damaged tissue in the acute phase following TBI could have considerable therapeutic and prognostic implications. However, it is questionable whether stroke thresholds are applicable to TBI. Therefore, the aim of this study was to determine physiological thresholds for the development of irreversible tissue damage in contusional and pericontusional regions in TBI, and to determine the ability of such thresholds to accurately differentiate irreversibly damaged tissue. This study involved 14 patients with structural abnormalities on late-stage MRI, all of whom had been studied with (15)O PET within 72 h of TBI. Lesion regions of interest (ROI) and non-lesion ROIs were constructed on late-stage MRIs and applied to co-registered PET maps of CBF, CMRO(2) and oxygen extraction fraction (OEF). From the entire population of voxels in non-lesion ROIs, we determined thresholds for the development of irreversible tissue damage as the lower limit of the 95% confidence interval for CBF, CMRO(2) and OEF. To test the ability of a physiological variable to differentiate lesion and non-lesion tissue, we constructed probability curves, demonstrating the ability of a physiological variable to predict lesion and non-lesion outcomes. The lower limits of the 95% confidence interval for CBF, CMRO(2) and OEF in non-lesion tissue were 15.0 ml/100 ml/min, 36.7 mumol/100 ml/min and 25.9% respectively. Voxels below these values were significantly more frequent in lesion tissue (all P < 0.005, Mann-Whitney U-test). However, a significant proportion of lesion voxels had values above these thresholds, so that definition of the full extent of irreversible tissue damage would not be possible based upon single physiological thresholds. We conclude that, in TBI, the threshold of CBF below which irreversible tissue damage consistently occurs differs from the classical CBF threshold for stroke (where similar methodology is used to define such thresholds). The CMRO(2) threshold is comparable to that reported in the stroke literature. At a voxel-based level, however (and in common with ischaemic stroke), the extent of irreversible tissue damage cannot be accurately predicted by early abnormalities of any single physiological variable.

Short-term grief after an elective abortion

OBJECTIVE

To identify the short-term grief response after elective abortion.

DESIGN

Descriptive, comparative study.

SETTING

Instruments were administered in a women's health clinic.

PARTICIPANTS

Ninety-three women, 45 who had a history of elective abortion within the past 1 to 14 months and 48 who had never had an abortion. Inclusion criteria included no perinatal losses within the past 5 years; no documented psychiatric history; and ability to read, write, and comprehend English.

MAIN OUTCOME MEASURES

Nature and intensity of short-term grief.

RESULTS

Women with a history of elective abortion experienced grief in terms of loss of control, death anxiety, and dependency. Although there were no statistically significant differences in the intensity of grief in women who had a history of elective abortion and the comparison group, there was an overall trend toward higher grief intensities in the abortion group. Presence of living children, perceived pressure to have the abortion, and the number of abortions appear to affect the intensity of the short-term grief response.

CONCLUSION

Elective abortion has the potential for eliciting a short-term grief response. Research is needed to identify which women are at greatest risk. This grief response should be acknowledged and appropriate interventions undertaken.

Design of biplanar gradient coils for magnetic resonance imaging of the human torso and limbs

A method is described for design of gradient coils of unconventional geometry for MRI that is based on the superpositions of magnetic fields arising from individual current elements calculated by the Biot-Savart Law. Use of an optimization method based on a genetic algorithm enables a wide diversity in the shapes of coil that can be modeled. To exemplify this a two axis, biplanar gradient set is presented; this geometry offers good access for rectangular objects whilst holding the coils closer to the region of interest than is possible for cylindrical configurations. The inner dimensions of the gradient set were 40.0 x 24.4 x 40.0 cm and the gradient efficiencies were 0.3 and 0.4 mT m(-1) A(-1) in the z- and y- directions respectively over a 15 cm diameter region. Correction of signals arising from regions for which gradient linearity was not optimized was successful for the monotonic region within the set; the largest cuboid from which the MR signal could be processed to produce an undistorted image is of dimensions 36.3 x 17.2 x 24.4 cm.

Initial experience with the advanced breast biopsy instrumentation system

BACKGROUND

Advanced breast biopsy instrumentation is a recently designed alternative to large-core stereotactic and open needle localized breast biopsies. This minimally invasive technique uses digital stereotactic imaging to perform excisional biopsies of suspicious, nonpalpable mammographic lesions. The role of the ABBI system in the management of breast cancer has not yet been defined.

METHODS

A retrospective review to evaluate the safety, accuracy, and cost effectiveness of the ABBI system as performed by a single surgeon on 107 patients from February 1, 1997 to January 31, 1998. We also discuss the use of the ABBI system as a therapeutic breast cancer technique. All patients had nonpalpable mammographic lesions. The mammographic abnormalities were either architectural distortion, microcalcifications, or stellate and nodular densities.

RESULTS

Using the ABBI stereotactic unit, 110 breast biopsies were performed in 107 patients during a 12-month period. The mammographic abnormality was accurately localized and successfully biopsied in 99% (109 of 110) of the procedures as confirmed by specimen radiographs, stereotactic images, permanent pathologic sections, and 6-month follow-up mammograms. There were no intraoperative complications. Two patients developed postoperative wound hematomas and there was 1 postoperative wound infection. Six in situ cancers and 21 invasive cancers were diagnosed with the ABBI system. Two additional invasive cancers were diagnosed in patients with ductal carcinoma in situ at reexcision. Four patients with invasive ductal carcinoma and 1 patient with ductal carcinoma in situ had negative margins on their stereotactic biopsies and did not undergo reexcision by lumpectomy or mastectomy. Each of the 4 patients with invasive ductal carcinoma underwent axillary node dissections with postoperative radiation therapy and chemotherapy or tamoxifen. During the study period, the average hospital patient charge for a stereotactic breast biopsy was $2,377.75, and for an open excisional needle localized biopsy it was $3,028.00 (P <0.05). The stereotactic breast biopsy offered a total cost savings of $71,527.50 in our series of patients.

CONCLUSION

Advanced breast biopsy instrumentation is a safe, accurate, and cost-effective method for performing breast biopsies. In addition, the ABBI system may be able to excise small in situ or invasive breast cancers.

Laparoscopic cholecystectomy in an academic hospital: evaluation of changes in perioperative outcomes

OBJECTIVE

Evaluate changes in perioperative outcomes over an 82-month period in patients undergoing laparoscopic cholecystectomy by a single attending surgeon in an academic hospital.

METHODS

A retrospective review of 1025 consecutive patients undergoing laparoscopic cholecystectomy from September 1992 to February 1997 was compared to the initial 600 patients from May 1990 to August 1992. Statistical analysis included Chi square with Yates correction and Fischer's exact test.

RESULTS

Over the 82-month period there were no significant differences in the overall conversion rate to open cholecystectomy (p=0.26), intraoperative complications (p = 0.81), postoperative complications (p = 0.054) or mortality rates (p=0.66). There were 3 (0.5%) bile duct injuries in the initial 600 patients and only 1 (0.1%) in the group of 1025 patients (p=0.065). There was an increase (p<0.001) in laparoscopic cholecystectomies performed for acute cholecystitis and biliary dyskinesia and an increase (p<0.001) in the percentage of cases performed overall and for acute cholecystitis by the surgery residents over the last 54 months. Despite this, the conversion rates to open cholecystectomy in patients with acute cholecystitis decreased (p < 0.001) over the last 54 months. Additionally, more patients (p < 0.001) were discharged on the day of surgery in the most recent group.

CONCLUSION

Laparoscopic cholecystectomy can be performed safely by surgery residents under the direct supervision of an experienced laparoscopist without significant changes in perioperative outcomes. Despite an increased percentage of cases being performed for acute cholecystitis over the last 54 months, conversion rates to open cholecystectomy and biliary tract injury rates have decreased, and the perioperative morbidity has remained the same.

Spontaneous splenic rupture due to isolated splenic peliosis

Peliosis is a rare condition in which blood-filled cysts occupy the parenchyma of solid organs. It most commonly involves the liver or liver and spleen, but isolated cases of splenic peliosis have been documented. Spontaneous splenic hemorrhage from splenic peliosis has been reported in the literature only 6 times. We present the seventh known case of spontaneous hemorrhage from a peliotic spleen in an otherwise healthy man.

Multicenter evaluation of the MicroScan Rapid Gram-Negative Identification Type 3 Panel

The accuracy and performance of the revised MicroScan Rapid Gram-Negative Identification Type 3 Panel (Dade MicroScan Inc., West Sacramento, Calif.) were examined in a multicenter evaluation. The revised panel database includes data for 119 taxa covering a total of 150 species, with data for 12 new species added. Testing was performed in three phases: the efficacy, challenge, and reproducibility testing phases. A total of 405 fresh and stock gram-negative isolates comprising 54 species were tested in the efficacy phase; 96.8% of these species were identified correctly in comparison to the identification obtained either with the API 20E system (bioMérieux Vitek, Hazelwood, Mo.) or by the conventional tube method. The number of correctly identified isolates in the challenge phase, including new species added to the database, was 221 of 247, or 89.5%, in comparison to the number correctly identified by the conventional tube method. A total of 465 isolates were examined for intra- and interlaboratory identification reproducibility and gave an agreement of 464 of 465, or 99.8%. The overall reproducibility of each individual identification test or substrate was 14,373 of 14,384, or 99.9%. The new Rapid Gram-Negative Identification Type 3 Panel gave accurate and highly reproducible results in this multiple-laboratory evaluation.

Effect of smoking cessation upon circulatory responses to reactive hyperemia and cold pressor stress

Local and sympathetic nervous system stress tests were administered prior to and following a 5-d smoking cessation program to determine the effects of short term smoking cessation upon peripheral circulation. Reactive hyperemia (RH) tests were performed on the forearm as a local dilatory stressor. Finger blood flow responses to cold pressor (CP) stresses were used to access stimulation of the sympathetic nervous system. Measures of heart rate and total forearm or finger blood flow, pulse volume and rate of blood delivery were obtained continuously during each stress test. Smoking cessation produced a significant decrease (0.01 < p < 0.05) in heart rate during both the RH and CP test sequences. Grouped mean peak forearm blood flow (Mean difference = 2.11 ml.100 ml-1.min-1; p < 0.05) and pulse volume (Mean difference = 0.04 ml.100 ml-1.pulse-1; p < 0.01) were both significantly greater following occlusion during the post-cessation RH tests than during the similar test before smoking cessation. Both finger pulse volume and rate of blood delivery were significantly greater (0.01 < p < 0.05) during the recovery portion of the post-cessation CP tests than during the same period of the pre-cessation tests. Thus, smoking cessation significantly altered both the locally mediated and central nervous system controlled responses to externally applied stressors.

Laparoscopic cholecystectomy in a community hospital: experience with 600 laparoscopic cholecystectomies

We reviewed 600 patients who underwent laparoscopic cholecystectomy (LC) in a teaching community hospital from May 1990 to August 1992. The safety, efficacy, morbidity, and mortality of LC, as performed by one surgeon or under his direct supervision, were studied. Five hundred forty-eight patients (91.3%) were treated electively; 52 (8.7%) were admitted for acute cholecystitis (41) or gallstone pancreatitis (11). Mean operating time was 54 min, with a range of 20 to 145 min. Twenty-four (4%) patients required conversion to traditional (open) cholecystectomy. Operative cholangiograms were completed in 106 patients. These revealed choledocholithiasis in 7. Five hundred thirty-seven patients (89.5%) were discharged within 24 h and 564 (94%) within 48 h. The overall morbidity of 9.2% compared favorably with both open and laparoscopic series previously reported. Three patients (0.5%) had small lacerations of the anterior wall of the common duct. Two were recognized and repaired immediately. The third patient came for treatment on the fifth postoperative day and was stented by a T-tube. There was 1 death in this group--a myocardial infarction on postoperative day 4.

Differences in outcome of transurethral resection of the prostate for benign prostatic hypertrophy between three diagnostic categories

As part of a prospective cohort study of 388 men undergoing transurethral resection of the prostate (TURP) for benign prostatic hypertrophy, pre-operative factors and the outcome of surgery during the first post-operative year were compared between patients in whom their surgeon felt the principal reason for operating was chronic retention (37%), acute retention (with no chronic retention) (28%), or symptomatic prostatism (with no history of chronic or acute retention) (35%). Although in many respects the patients in the 3 diagnostic categories were similar, patients with chronic retention were more likely to be younger, of higher social class and to have worse general health. Patients with acute retention were more likely to present with a urinary tract infection and to have electrocardiographic abnormalities, and symptomatic patients presented with more severe urinary symptoms. Minor differences between the categories with regard to post-operative morbidity and mortality were not statistically significant at the 5% level. However, some significant differences did exist. Patients with acute retention were more likely to experience urinary and non-urinary infections and impotence after surgery, while symptomatic patients reported less improvement in their health status as regards pain and social isolation. These results suggest that the method of categorisation is clinically valid and a necessary distinction to make when auditing TURP.

Mortality, morbidity and complications following transurethral resection of the prostate for benign prostatic hypertrophy

A total of 388 men undergoing transurethral resection of the prostate for benign prostatic hypertrophy during 1988 entered a prospective cohort study designed to examine the outcome of surgery during postoperative year 1. Self-administered questionnaires were completed preoperatively, and at 3, 6 and 12 months postoperatively. The surgeons completed 1 questionnaire shortly after surgery and another questionnaire 3, 6 or 12 months later. The mortality rate during the 12 months of followup was 2.8% (11 deaths). The surgeons reported perioperative complications in 14% of the patients and immediate postoperative complications, excluding urinary tract infections, in 17%. During the first 3 months postoperatively 38% of the patients reported incontinence and 25% had a urinary tract infection. Between 6 and 12 months postoperatively only 12% of the patients were troubled by either condition. The postoperative prevalence of impotence (24%) did not alter during followup and was similar to that reported preoperatively (22%). Of the patients 74% reported feeling better and 78% experienced a decrease in the overall level of symptoms postoperatively. The improvement in symptom levels was greatest in those with the most severe preoperative symptoms, and obstructive symptoms were alleviated slightly more than irritative symptoms.

Rapid Clonal Growth Measurements at the Single-Cell Level: Gel Microdroplets and Flow Cytometry

We describe a new, general method for rapidly measuring clonal growth of large numbers of individual members of a cell population. This method is based on microculture of individual colony-forming units in gel microdrops (GMDs; here agarose; 20 to 90 mu in diameter), which are sufficiently robust to be handled much like cells, and diffusionally transparent for molecules of interest. Flow cytometry provides rapid measurements of GMD-entrapped microcolonies, and permits subpopulation analysis. Here the method is demonstrated with mammalian, fungal and bacterial species. Additional results illustrate rapid determination of a drug-resistant subpopulation in a mixed species sample, and nutrient sensitivity for a murine hybridoma.

Urothelial grafts in mice

Mouse bladder epithelium has been successfully transplanted to the bladders of syngeneic mice and has survived for at least twenty weeks. The fate of the transplanted tissue was followed using a fluorescein label. The recipient bladders were prepared by stripping the urothelium either by a surgical or a chemical method. The possibility of adopting a comparable technique for the treatment of early bladder cancer in man is discussed.

Rapid microbial detection and enumeration using gel microdroplets and colorimetric or fluorescence indicator systems

A new micromethod employing gel microdroplets (GMDs) and optical measurements can be used for rapid detection and enumeration of viable microorganisms (J. C. Weaver, G. B. Williams, A. M. Klibanov, and A. L. Demain, Bio/Technology 6:1084-1089, 1988) and has several potential applications in clinical microbiology. This method involves entrapping microorganisms in GMDs (10 to 100 microns in diameter) which are surrounded by a hydrophobic (low dielectric) fluid, subsequently distinguishing occupied and unoccupied GMDs with colorimetric or fluorescence indicators, counting both occupied and unoccupied GMDs, and applying Poisson statistical analysis. Acid-producing microorganisms were used to compare colorimetric and fluorescence pH indicator systems. Fluorescence systems were generally superior, particularly for detection before microbial growth occurred. Although colorimetric detection was reasonably fast for fast-growing microorganisms, significantly longer times were needed for slow-growing microorganisms. We investigated the dependence of the detection time on microbial division time, GMD size, and buffering capacity of the medium within GMDs. It was found possible to use a single preparation of GMDs, containing a range of GMD sizes, to simultaneously provide a viable enumeration of growing and nongrowing (e.g., stressed) cells. This was possible because small GMDs responded rapidly to both growing and nongrowing cells, while large GMDs, although slower, responded much more rapidly to growing cells than to nongrowing cells. Separate analysis of small and large GMDs in the same preparation yielded two enumerations, one of nongrowing cells and the other of growing cells. GMDs can also be used with conventional light microscopy to detect and enumerate fast-growing acid-producing bacteria much more quickly than conventional plating methods.

Doctoral preparation of nursing faculty

Is the doctorate necessary for all nurse educators? Should nurse educators hold a doctorate or is a non-nursing doctorate acceptable? The authors report on a survey which looked at information concerning the number of doctorally prepared nursing faculty and the institutional requirement of a doctorate as the terminal degree in nursing.

Cholecystectomy in the elderly

A series of 347 elderly patients undergoing cholecystectomy has been presented. The older a patient is at the time of cholecystectomy, the more likely it is for that patient to present with an acute biliary complication. The elderly tolerate biliary tract operations quite well, especially before acute complications of cholelithiasis occur. Early cholecystectomy can prevent the morbidity associated with the natural progression of cholelithiasis. Whether prophylactic cholecystectomy for asymptomatic cholelithiasis would be cost effective is an issue that can be resolved only when further data regarding the natural history and incidence of cholelithiasis in the elderly is known.

Albumin adsorption and retention on C18-alkyl-derivatized polyurethane vascular grafts

The short-term albumin affinity and thrombo-resistance of a polyether polyurethane vascular graft have been improved. The method is based on the C18 alkylation of the polymer. Thrombus formation by a planimetric technique and albumin retention on wire-reinforced polyurethane tubes, both C18 alkylated and untreated, were measured in short-term (4-h) exposure at femoral arterial sites in the dog. 125I-Albumin was preabsorbed on tubes and then exposed to blood for successive 2-h periods. Albumin uptake on alkylated tubes prior to blood exposure and retention following 2 h of blood exposure were significantly greater than on controls. Following a fast desorption phase in blood, the remaining albumin was more slowly desorbed from alkylated than from control tubes. Reincubation with albumin and blood reexposure produced a similar tendency, suggesting blood conditioning does not reduce the albumin affinity-enhancing property of C18 alkylation in the short term. Blood-preconditioning experiments suggested endogenous albumin has a high affinity for the C18-alkylated surface. Scanning electron microscopic examination showed thrombus and platelet densities were higher on control than on alkylated surfaces. These results suggest in vivo albumin affinity is increased for C18-alkylated polyurethane, which may be linked to decreased thrombus formation on these surfaces.

Primary squamous cell carcinoma of the colorectum: case report and literature review of a rare entity

A case of primary squamous cell carcinoma of the rectum is presented. Although it is a rare condition, the diagnosis, treatment, and natural history of the disease are similar to that of adenocarcinoma of the colorectum. The patient in this report has done well to date with an abdominal perineal resection and early post-operative radiation. A review of the literature reveals that the precise etiology of this entity remains unknown.

Distal duodenal carcinoma and intussusception

Adenocarcinoma of the duodenum is an uncommon malignancy that usually presents itself with either obstructive symptoms or jaundice, depending on its location. The diagnosis should be suspected in any patient with a high small bowel obstruction, weight loss, or chronic abdominal pain. Endoscopy and barium contrast x-ray films are the preferred initial studies; enteroclysis may provide additional information. Surgical resection offers the only hope for long-term survival, which should approach 50% with resectable tumors.

Management of intra-abdominal aneurysms associated with periarteritis nodosa

Periarteritis nodosa is a disease of small and medium-sized arteries, frequently associated with multiple visceral artery aneurysms. Infrequently, these aneurysms rupture, usually with fatal results. A case of spontaneous rupture of a middle colic artery aneurysm in a patient with periarteritis nodosa is reported, and similar cases in the literature are reviewed. Treatment of a ruptured visceral artery aneurysm requires ligation or resection of the aneurysm without delay. Residual aneurysms are treated with cyclophosphamide and/or prednisone in an attempt to induce regression of the aneurysms. An arteriogram performed after 3 to 4 months of medical therapy determines the need for further surgical intervention.

Total parenteral nutrition by a nutrition support team: improved quality of care

Most of the studies that have examined the effect of nutrition support teams (NST) on the quality of total parenteral nutrition (TPN) have found reductions in the frequency of metabolic and central venous catheter related complications. Previous studies have not examined the patterns of nutrient delivery (eg, calories and protein) when TPN is provided either by a primary physician or by a NST. We compared the quality of TPN care provided by our NST or by primary physicians utilizing nonspecialized hospital personnel and resources. As expected, catheter complications were significantly less frequent in NST patients. Assessment of nutritional status and nutrient requirements as well as nitrogen balance were performed and documented significantly more often in NST patients. In addition, nutritional goals for calories and protein were achieved and positive nitrogen balance documented more often in NST patients. The need to consult the NST physician to utilize the NST was not well received by primary attending and resident physicians and resulted in nonuse of the team. In the future, modification of NST policies will be explored to encourage greater utilization of the NST without compromising the high standard of nutrition care delivered by the NST.

NH3 and propionate modulate the morphological response of aggregation-competent Dictyostelium discoideum to cAMP

Two metabolites, NH3 and propionic acid, are known to act as morphogens during the development of Dictyostelium discoideum, specifically altering the course of morphogenesis and cytodifferentiation. They have also been shown to modulate the cAMP relay in this organism: NH3 by restricting intracellular accumulation, and propionate by inhibiting extracellular release. In the present study, we utilized the light-scattering properties of aggregation-competent cells in agitated suspension to demonstrate that the morphological responses of such cells to exogenous cAMP are also modulated by NH3 and propionate in a manner that has interesting implications for the overall control of morphogenetic movements in D. discoideum. Our experiments were conducted using a newly designed continuous-flow apparatus that represents a significant improvement in the technique. The apparatus is described in detail.

Modulation of the cAMP relay in Dictyostelium discoideum by ammonia and other metabolites: possible morphogenetic consequences

Using a perfusion technique (P.N. Devreotes, P.L. Derstine, and T.L. Steck, 1979, J. Cell Biol. 80, 291-299), it has been shown that cAMP secretion by aggregation-competent cells in response to an exogenous cAMP signal is significantly reduced by exposure to NH4Cl or any of a set of carboxylic acids that includes propionate, succinate, pyruvate, and acetate. The effects of NH4Cl and any of the carboxylic acids are additive and the combinations restrict cAMP secretion to barely detectable or insignificant levels. The inhibitions are rapidly expressed, and are reversible. The activity of NH4Cl is marked at pH 7.2 and undetectable at pH 6.2. Hence, NH3 is presumably the active molecular species. Propionate activity is significantly greater at pH 6.2 than 7.2, indicating that the un-ionized acid is the active species. The data presented herein indicate that these effects are exerted via two separate and independent routes. During exposure of cAMP-stimulated cells to NH4Cl, the decrease in intracellular cAMP accumulation was even greater than the decrease in extracellular accumulation. Hence, NH3 appears to act as a cAMP accumulation inhibitor (CAI). In contrast, exposure to carboxylic acid concentrations that drastically reduce extracellular cAMP accumulation can actually enhance or, at worst, only slightly reduce intracellular accumulation. Hence, the carboxylic acids appear to act as cAMP release inhibitors (CRI). Stationary phase cells incubated on solid substratum in the presence of NH4Cl plus succinate (or propionate) for 18 hr failed to exhibit even the earliest signs of aggregation. If then harvested and redeposited in the absence of the metabolites, they proceeded through the morphogenetic sequence with approximately normal kinetics, suggesting that no significant morphogenetic competence had been achieved during their previous tenure. The morphogenetic implications of cAMP relay modulation are discussed.

Reversible inhibition of aggregation-related cohesivity in Dictyostelium discoideum by diffusible metabolites

Evidence presented elsewhere (G.B. Williams, E.M. Elder, and M. Sussman 1984, Dev. Biol. 105, 377-388) indicates that NH3 and certain carboxylic acids including propionate, succinate, and acetate modulate the cAMP relay in Dictyostelium discoideum. The former appears to act as a cAMP accumulation inhibitor, the latter as cAMP release inhibitors. The cohesive properties of aggregation competent cells have been assayed quantitatively in the presence of these modulators. The following results were obtained: (1) At pH 7.5, EDTA-resistant cohesivity was greatly inhibited by NH4C within the concentration range tested (30-3.8 mM). Even at the higher concentrations the effect was not immediate but required ca. 10 min for full expression. At the lower concentrations, the inhibitory level was only slightly reduced but the time for full expression progressively increased. At pH 6.5, the level of inhibition was marginal, indicating that NH3 is the active molecular species. By themselves, neither ambient pH nor ionic strength appeared to affect cohesive performance within the ranges employed. The inhibition was immediately and completely reversed upon removal of NH4Cl or a shift of ambient pH from 7.5 to 6.5. The presence of cycloheximide did not affect the recovery of cohesivity after NH4Cl removal. (2) The presence of 15 mM succinate, propionate, or acetate also reduced cell cohesivity. The timing and extent of the inhibition were identical at pH 7.5 and 6.5. The inhibition was expressed immediately and was reversible. Each of the acids acted synergistically with NH4Cl. The relative potencies of these metabolites acting singly or in combination as inhibitors of cohesivity corresponded roughly to their potencies as modulators of the cAMP relay (Williams et al., 1984). (3) The sensitivity to the metabolites was stage specific, being maximal during and shortly after aggregation and disappearing abruptly at 11-12 hr. This corresponds to the time at which this cohesive system, responsible for the end-to-end cell associations evident during aggregation (H. Beug, G. Gerisch, S. Kempff, V. Riedel, and G. Cremer, 1970, Exp. Cell. Res. 63, 147-158) is supplanted by a newly arisen, serologically and genetically distinct system which thereafter maintains the integrity of the aggregate (C. Steinemann and R.W. Parish, 1980, Nature (London) 286, 721-724; D.K. Wilcox and M. Sussman, 1981, Dev. Biol. 82, 102-112, and Proc. Natl. Acad. Sci. USA 78, 358-362; C.L. Saxe III and M. Sussman, 1982, Cell 29, 755-759). The activities of the metabolites, detailed above, are discussed in relation to their previously demonstrated activities as morphogens.

The multidisciplinary team approach to exenteration of the pelvis

The experience of a newly formed, multidisciplinary, pelvic exenteration team is presented which consists of a gynecologic oncologist, a general surgeon and a urologist. The first 20 exenterations performed by this team are reviewed. Nine patients had no postoperative problems, and of the 11 patients who did have complications, all but two, which resulted in death, were corrected without resultant debilitation. Fourteen of the 18 patients who survived the operation are tumor-free for as long as three years postoperatively. Operative proficiency as well as operative mortality and morbidity have certainly improved quite significantly as the team has gained experience.

The role of parathyroidectomy in the management of hyperparathyroidism in patients on maintenance haemodialysis and after renal transplantation

Between March 1964 and March 1980, 36 (34 dialysis, 2 transplant) of 327 patients accepted for the maintenance dialysis/transplantation programme at Charing Cross Hospital were submitted to parathyroidectomy. There were four main indications: persistent hypercalcaemia, progressive phalangeal erosions, aseptic necrosis of the femoral head and height loss with abnormal bone biopsy despite normal hand radiographs. At parathyroidectomy, 4 glands were removed in 1 patient, 3 1/2 glands in 24, 3 glands in 7, 2 glands in 3 and a single large gland in 1 patient. The operation was followed by improvement in 28 patients, no change in 5, and progression of hyperparathyroidism in 3.2 of the 28 patients who improved later relapsed and were treated with 1,25-(OH)2 vitamin D3. 4 patients were submitted to a further parathyroidectomy and improved considerably. We would conclude that, although parathyroidectomy is an effective and safe procedure, it is to be hoped that careful monitoring of bone state and early administration of 1,25-(OH)2 vitamin D3 may reduce the need for parathyroidectomy.

Carcinoma of the bladder treated by interstitial irradiation

A retrospective study is presented of 180 patients with clinically infiltrating transitional cell carcinoma of the bladder treated by interstitial irradiation. The cases were re-classified by clinical tumour extent and histopathological grace according to the UICC (1978) classification. The actuarial survival rates and complications are presented and treatment policy reviewed.