The RAIS Device for Global Surgery: Using a Participatory Design Approach to Navigate the Translational Pathway to Clinical Use

Background: Over 5 billion people worldwide have no access to surgery worldwide, typically in low-resource settings, despite it being a primary life-saving treatment. Gas Insufflation-Less Laparoscopic Surgery (GILLS) can address this inequity, by improving current GILLS instrumentation to modern surgical standards. Objective: to develop and translate a new Retractor for Abdominal Insufflation-less Surgery (RAIS) into clinical use and thus provide a context-appropriate system to advance GILLS surgery. Methods: A collaborative multidisciplinary team from the UK and India was formed, embedding local clinical stakeholders and an industry partner in defining user and contextual needs. System development was based on a phased roadmap for ‘surgical device design in low resource settings’ and embedded participatory and frugal design principles in an iterative process supported by traditional medical device design methodologies. Each phase of development was evaluated by the stakeholder team through interactive workshops using cadaveric surgical simulations. A Commercialisation phase undertook Design to Manufacture and regulatory approval activities. Clinical validation was then conducted with rural surgeons performing GILLS procedures using the RAIS system. Semi-structured questionnaires and interviews were used to evaluate device performance. Results: A set of user needs and contextual requirements were defined and formalised. System development occurred across five iterations. Stakeholder participation was instrumental in converging on a design which met user requirements. A commercial RAIS system was then produced by an industry partner under Indian regulatory approval. This was successfully used in clinical validation to conduct 12 surgical procedures at two locations in rural India. Surgical feedback showed that the RAIS system provided a valuable and usable surgical instrument which was appropriate for use in low-resource contexts. Conclusions: Using a context-specific development approach with close engagement of stakeholders was crucial to develop the RAIS system for low-resource regions. The outcome is translation from global health need into a fully realized commercial instrument which can be used by surgeons in low-resource regions across India.

Identification of new Fas mutations in a patient with autoimmune lymphoproliferative syndrome (ALPS) and eosinophilia

Autoimmune lymphoproliferative syndrome (ALPS) is a rare, newly recognized, chronic lymphoproliferative disorder in children and is characterized by lymphadenopathy, splenomegaly, pancytopenia, autoimmune phenomena and expansion of double-negative (DN) T lymphocytes (TCR alpha beta+, CD4-, CD8-). Defective lymphocyte apoptosis caused by mutations of the Fas (CD95) gene has been linked in the pathogenesis of ALPS, as binding of Fas-ligand to Fas can trigger apoptosis. Of the ALPS cases reported to date, point mutations, frameshifts and silent mutations in Fas all have been identified. We report two new point mutations in Fas in a child with ALPS and eosinophilia; studies on other family members established the pattern of inheritance for these mutations. Flow cytometric analysis of blood and tissues (spleen, lymph node, bone marrow) revealed abnormally expanded populations of DN T lymphocytes. Furthermore, activated lymphocytes and IFN gamma-activated eosinophils were resistant to Fas-mediated apoptosis. Eosinophil resistance to Fas-mediated apoptosis has not been previously described in ALPS. Sequencing of Fas revealed two separate mutations not previously reported. One mutation, a C to T change at base 836, was a silent mutation inherited from the mother, while the second mutation, a C to A change at base 916, caused a non-conservative amino acid substitution in the death domain of Fas, changing a threonine to a lysine. This mutation is associated with a predicted change in the structure of a part of the death domain from a beta-pleated sheet to an alpha-helix. We speculate that the mutation in the death domain prevents the interaction of Fas with intracellular mediators of apoptosis and is responsible for the autoimmune manifestations of ALPS and the abnormal lymphocytosis and eosinophilia in this patient.

Bropirimine as neoadjuvant therapy decreases residual disease and expression of markers PCNA and TGF-beta 1 in a rat orthotopic prostate adenocarcinoma

The role of bropirimine in prostate cancer remains unexplored. To address the efficacy of this immune modulator as neoadjuvant therapy we utilized the orthotopic placement of the Dunning AT-3 tumor. 2.4-2.6 x 10(6) Dunning AT-3 cells were injected into the ventral prostates of 50 Copenhagen X Fischer rats. Animals were then divided into 5 groups consisting of: 1) untreated controls; 2) those treated with ventral prostatectomy alone (performed 10-12 days following tumor cell inoculation); 3) those treated with ventral prostatectomy plus bropirimine (10 mg/kg) on postimplantation days 1, 3, 5, 10 and 11; 4) those treated with ventral prostatectomy plus bropirimine (100 mg/kg), at the same schedule; and 5) those treated with ventral prostatectomy plus bropirimine (500 mg/kg), at the same schedule. Animals were sacrificed 10 days after prostatectomy, autopsied, and residual disease was weighed. Prostate weights upon removal following neoadjuvant treatment and residual disease remaining after 20-22 days were expressed in grams (g). Following prostatectomy, mean prostate weights were: Group 2, 0.67 +/- 0.11; Group 3, 0.53 +/- 0.11; Group 4, 0.54 +/- 0.12; Group 5, 0.44 +/- 0.09. The effect of bropirimine was significant (p = 0.0001) by multiple regression analysis. In addition, mean residual tumor weights (expressed in grams) after 20-22 days were: Group 1, 12.7 +/- 1.9; Group 2, 6.7 +/- 4.8; Group 3, 5.2 +/- 5.9; Group 4, 3.8 +/- 3.5; and Group 5, 2.8 +/- 3.5. The effect of bropirimine was not significant (p = 0.07) by multiple regression analysis. However, prostatectomy alone, by Student's test, significantly (p = 0.04) reduced residual mean tumor weights by 47% and the additional effect of bropirimine upon residual disease was significant (p = 0.038) if a Chi-square analysis is applied. Finally, a multivariate analysis of the overall effect of bropirimine in rats treated with prostatectomy was significant (p = 0.002). The effect of bropirimine on expression of proliferating cell nuclear antigen (PCNA) and transforming growth factor beta 1 (TGF-beta 1) was also evaluated immunohistochemically and expression of both tumor markers was significantly reduced (p < 0.05). We conclude that bropirimine may have a role as a neoadjuvant therapy when combined with prostatectomy.

Survival of Mexican-American males with seminoma

OBJECTIVE

The objective was to determine if ethnicity was a prognostic variable in survival outcomes for testicular seminoma.

MATERIALS

Eighty-seven consecutive patients with a histologic diagnosis of seminoma treated at University of illinois Hospitals were evaluated.

RESULTS

There were 52 (57%) white, 22 (24%) African-American, 16 (18%) Mexican-American and 1% Asian patients. Adjusted survivals for the life-table method were 84% and 80% for the whites and Africa-American patients and 69% for the Hispanic patients. The poorer outcome appeared to be related to stage at diagnosis.

CONCLUSION

In this population with testicular seminoma Mexican-American patients appear to have a worse prognosis than other ethnic groups. These differences were associated to a delayed diagnosis probably due to cultural influences.

Paracetamol (acetominophen) sulphoconjugation in man: no correlation with tyramine sulphoconjugation

There is considerable evidence that subjects vulnerable to endogenous depression excrete less tyramine sulphate after an oral dose of free tyramine than controls (the tyramine test). In this study, 26 psychiatric inpatients, exhibiting a wide range of responses to the test, and 10 normal controls were challenged with oral doses of paracetamol and tyramine on two separate occasions. Urinary output of paracetamol sulphate and paracetamol glucuronide in all subjects was monitored but there were no significant correlations with tyramine sulphate output. Thus, the output of these metabolites appears to be under complex control, and paracetamol cannot be substituted for tyramine in the "tyramine test". The basic deficit responsible for low values in the tyramine test is unlikely to stem from sulphate depletion or a generalised disturbance of the sulphation system, and remains obscure.

Adipose tissue growth patterns during human gestation: a histometric comparison of buccal and gluteal fat depots

Morphometric analysis of fat lobule size and number, and fat cell number in middle buccal and gluteal fat depots during the prenatal period was carried out using histological sections from 88 typical-for-age or normal human prenates of both sexes. The sample ranged from 110 to 385 mm Crown-Rump length (or from 14 through 42 gestational weeks). Compared with the buccal fat pad, the gluteal fat was one to four weeks delayed in lobule maturation. In addition to fat maturation differences between buccal and gluteal fat sites, gluteal fat characteristically showed fewer but larger fat lobules than did the buccal fat pad. Conversely there appeared a larger number of fat cells per unit area in the buccal fat than in the gluteal fat. Fat accumulation in human buccal and gluteal fat depots include differences in growth timing and magnitude, but also different developmental patterns. These patterns suggests our hypothesis that while lobule hyperplasia and hypertrophy occur at both sites, gluteal fat lobules grow primarily through lobule hypertrophy whereas the buccal fetal pad grows through lobule hyperplasia.

A New Look at the Saturn System: The Voyager 2 Images

Voyager 2 photography has complemented that of Voyager I in revealing many additional characteristics of Saturn and its satellites and rings. Saturn's atmosphere contains persistent oval cloud features reminiscent of features on Jupiter. Smaller irregular features track out a pattern of zonal winds that is symmetric about Saturn's equator and appears to extend to great depth. Winds are predominantly eastward and reach 500 meters per second at the equator. Titan has several haze layers with significantly varying optical properties and a northern polar "collar" that is dark at short wavelengths. Several satellites have been photographed at substantially improved resolution. Enceladus' surface ranges from old, densely cratered terrain to relatively young, uncratered plains crossed by grooves and faults. Tethys has a crater 400 kilometers in diameter whose floor has domed to match Tethys' surface curvature and a deep trench that extends at least 270 degrees around Tethys' circumference. Hyperion is cratered and irregular in shape. Iapetus' bright, trailing hemisphere includes several dark-floored craters, and Phoebe has a very low albedo and rotates in the direction opposite to that of its orbital revolution with a period of 9 hours. Within Saturn's rings, the "birth" of a spoke has been observed, and surprising azimuthal and time variability is found in the ringlet structure of the outer B ring. These observations lead to speculations about Saturn's internal structure and about the collisional and thermal history of the rings and satellites.

Contemporary indications for psychosurgery

The initial period of enthusiasm for the surgical treatment of certain psychiatric illnesses, has later given way to increasing rejection of this mode of therapy. But more recently there has been a reappraisal of the therapeutic possibilities of the modern refined operations, which are now receiving more objective assessment.

The effect of a proteolytic enzyem mixture (Orenzyme-Forte) on experimentally induced pulpitis

A proteolytic enzyme mixture, Orenzyme-Forte, containing trypsin, chymotrypsin, and ribonuclease was used to treat experimentally induced pulpitis in the teeth of three monkeys. Assessment by means of the criteria of Stanley showed that the enzyme mixture induced better healing than a zinc oxide--eugenol dressing. When the two were used simultaneously, a synergistic effect was seen. We suggest that this enzyme mixture may be useful in clinical practice in the treatment of pulpitis.