The E.A.E.S. Consensus Development Conferences on laparoscopic cholecystectomy, appendectomy, and hernia repair. Consensus statements--September 1994. The Educational Committee of the European Association for Endoscopic Surgery

Under the mandate of the Educational Committee of the European Association of Endoscopic Surgery (E.A.E.S.), three consensus development conferences (CDCs) were performed in order to assess the current status of the endoscopic surgical approaches for the treatment of cholelithiasis, appendicitis, and inguinal hernia. Consensus panels for the different disease states (10-13 members each) selected by the education committee on the basis of members' clinical expertise, academic activity, community influence, and geographical location weighed the evidence on the basis of published results according to the criteria for technology assessment: feasibility, efficacy, effectiveness, economy. Draft statements were prepared, discussed by the panels, and presented at plenary sessions of the 2nd European Congress of the E.A.E.S. in Madrid September 15-17, 1994. Following discussions final consensus statements were formulated to provide specific answers for each topic to a minimum of the following questions: 1. What stage of technological development is the endoscopic surgical procedure at (in September 1994)? 2. Is endoscopic surgery safe and feasible? 3. Is it beneficial to the patients? 4. Who should undergo endoscopic surgery? 5. What are the training recommendations? Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Laparoscopic appendectomy is presently at the efficacy stage of development, because most of the data on feasibility and safety originate from centers with special interest in endoscopic surgery: it is not yet the gold standard for acute appendicitis. Endoscopic hernia repair is presently a feasible alternative for conventional hernia repair if performed by experienced endoscopic surgeons. It appears to be efficacious in the short-term. The full text of the consensus panel's statements is given in this publication.

Protein kinase C and tyrosine kinase pathways regulate lipopolysaccharide-induced nitric oxide synthase activity in RAW 264.7 murine macrophages

1. In RAW 264.7 macrophages, lipopolysaccharide (LPS) and gamma-interferon (IFN gamma) alone or in combination stimulated the induction of nitric oxide synthase (iNOS) activity and increased the expression of the 130 kDa isoform of NOS. 2. LPS-induced NOS activity was reduced by incubation with CD14 neutralising antibodies and abolished in macrophages deprived of serum. 3. LPS stimulated a small increase in protein kinase C (PKC) activity in RAW 264.7 macrophages which was dependent on the presence of serum. However, IFN gamma did not potentiate LPS-stimulated PKC activity. 4. The protein kinase C inhibitor, Ro-318220, abolished both LPS- and IFN gamma-stimulated protein kinase C activity and the induction of NOS activity. 5. LPS- and IFN gamma-induced NOS activity was reduced by the tyrosine kinase inhibitor genestein. Genestein also reduced LPS-stimulated protein kinase C activity but did not affect the response to the protein kinase C activator, tetradecanoylphorbol acetate (TPA). 6. Nicotinamide, an inhibitor of poly-ADP ribosylation, abolished LPS- and IFN gamma-induced NOS activity. 7. Brefeldin A, an inhibitor of a factor which stimulates nucleotide exchange activity on the 21 kDa ADP-ribosylation factor, ARF, reduced LPS- and IFN gamma-induced NOS activity by approximately 80%. 8. These results suggest the involvement of protein kinase C, tyrosine kinase and poly-ADP ribosylation pathways in the regulation of the induction of nitric oxide synthase in RAW 264.7 macrophages by LPS and IFN gamma.

Randomized trial of modified Bassini versus Shouldice inguinal hernia repair. The Cologne Hernia Study Group

Between 1986 and 1992, 265 men of mean age 51 (range 16-75) years with a primary inguinal hernia were randomized to undergo surgery by staff surgeon or surgical resident and further randomized to receive a modified Bassini operation (transversalis fascia not divided but included in the repair) or Shouldice procedure. The follow-up rate was 92.1 per cent with a mean follow-up of 3.3 years. Recurrence developed in 12 of 125 patients with a Bassini procedure and two of 119 after a Shouldice repair (9.6 versus 1.7 per cent, P = 0.006). The recurrence rate was no different for staff surgeons and trainees (5.9 versus 5.6 per cent, P not significant). Multivariate analysis identified the presence of a direct hernia (P = 0.003) as the additional main factor for the development of recurrence.

Preoperative chemoradiation for adenocarcinoma of the pancreas and duodenum

PURPOSE

This study was designed to evaluate the effects of preoperative chemoradiation on resectability, response, local control, and survival in patients with local or local-regional involvement from carcinoma of the pancreas or cancer of the duodenum and to assess the associated toxicity of such treatment.

METHODS AND MATERIALS

This prospective pilot study of preoperative chemoradiation was initiated in 1986 for patients with clinical evidence of adenocarcinoma of the pancreas or duodenum without evidence of distant metastases. Radiation was given at 1.8 Gy per day to a total dose of 50.4 Gy. Two cycles of chemotherapy were given concurrent with radiation. On days 2-5 and 29-32, 5-fluorouracil (1 gm/m2/24 h x 4 days) was given, while mitomycin-C (10 mg/m2) was given on day 2 only. Surgical resection was 4-6 weeks following completion of chemoradiation. Thirty-one patients (17 male and 14 female) were entered on the protocol with a median potential follow-up of 4.5 years (range 6 months to 7.5 years). The median age was 64 years (range 32-73 years). Twenty-seven patients had pancreatic cancer (25 head, two body), while four patients had carcinoma arising from the duodenum. Twenty-one patients were initially judged to be unresectable and ten potentially resectable prior to chemoradiation.

RESULTS

Twenty-nine of 31 patients completed the entire course of radiation and both cycles of chemotherapy. Acute toxicity from chemoradiation consisted of nausea, vomiting, diarrhea, stomatitis, or hematologic suppression which was moderate to severe (Grade 3 or 4) in seven patients (23%). One patient died of sepsis following the first week of therapy. Seventeen patients (55%) underwent curative resection with subtotal or total pancreatectomy or Whipple resection (four duodenum, 13 pancreas) and two (2/17) had pathologic nodal involvement, while (0/17) none had involved margins. A complete pathologic response was seen in all four (4/4) patients with duodenal cancer and in none (0/13) with pancreatic cancer who underwent resection. The median postoperative hospitalization stay was 22 days (range 4-144 days). Of 17 patients who underwent curative resection, there were two postoperative mortalities (12%). Late complications have included abscess, one; and nonmalignant ascites, five. Ten of the 31 patients are alive. For patients with pancreatic cancer the median survival is 9 months, while survival at 1 year and 3 years are 36% and 19% overall and 60% and 43% at 1 and 3 years for those undergoing resection. Six of the 27 patients (22%) with pancreatic cancer are alive without recurrence. All four patients with duodenal cancer are alive without recurrence (12 months, 23 months, 35 months, 90 months).

CONCLUSION

Preoperative chemoradiation for cancer of the pancreas and duodenal region was relatively well-tolerated and enhanced resectability and downstaging of nodal metastases were suggested. The 3-year survival, particularly in patients who underwent resection, was high. For these reasons the applicability of this treatment regimen for pancreatic cancer is presently being studied in a group-wide multi-institutional Phase II trial. Chemoradiation for duodenal cancer has produced a complete pathologic response in all patients and survival has been excellent, suggesting efficacy of this regimen for duodenal cancer.

Identification of decorin proteoglycan in bovine tracheal serous cells in culture and localization of decorin mRNA in situ

Bovine tracheal submucosal gland serous cells in culture synthesize and secrete proteoglycans and not mucin glycoconjugates. We are interested in the characterization and role of these proteoglycans in airway secretions. The major [35S]methionine-labeled proteoglycan present is identified as the small chondroitin/dermatan sulfate proteoglycan decorin (PG II. PG40). Consistent with its identity as decorin this proteoglycan showed average apparent molecular weights of 75,000 to 130,000 with a core protein of an average, M(r) of about 40,000 and with glycosaminoglycan chains sensitive to chondroitinase ABC lyase of an average M(r) of about 25,000. These data were obtained from gel chromatographic and SDS-PAGE analyses. Northern blot analysis and partial amino acid sequencing of the purified protein further confirmed its identity as decorin. In situ hybridization studies using a decorin riboprobe revealed no expression of decorin in the surface epithelium and only low levels of expression in submucosal gland epithelial cells of bovine tracheal tissue. However, high levels of expression were localized to cells which are peripheral to tracheal submucosal gland epithelial cells and which contact with the extracellular matrix.

Phosphorylation of vimentin is an intermediate step in protein kinase C-mediated glycoconjugate secretion

We have previously shown that fibroblasts from patients with cystic fibrosis (CF) display a higher response to 4 beta-phorbol 12-myristate 13-acetate (PMA) than control fibroblasts for stimulation of both protein kinase C (PKC) cytosol-to-membrane translocation and glycoconjugate secretion. In this study we took advantage of these cells with differential responsiveness to PMA to investigate the endogenous substrate(s) involved in PKC stimulation of glycoconjugate secretion after verification of cystic fibrosis transmembrane conductance regulator gene expression in control and CF fibroblasts. We show that a 57-kDa protein that was associated with cytoskeleton and was identified as vimentin by immunoblotting emerged as a good candidate for mediating PKC stimulation of glycoconjugate secretion. 1) Its phosphorylation by PMA was abolished by PKC inhibition or depletion. 2) In both control and CF fibroblasts, the PMA-induced increase in its phosphorylation preceded the phorbol ester stimulation of glycoconjugate secretion. 3) For both processes, the concentration-response curves were superimposable, with higher maximal levels for CF fibroblasts relative to controls. 4) PMA-stimulated 57-kDa protein phosphorylation, like PMA-stimulated glycoconjugate secretion, was significantly increased by Ca2+. 5) Increased PMA phosphorylation of the 57-kDa protein as a result of okadaic acid inhibition of intracellular phosphatases was reflected in increased PMA stimulation of glycoconjugate secretion. In conclusion, 1) PMA phosphorylation of a cytoskeletal 57-kDa protein, identified as vimentin, appears to be an intermediate step in PKC stimulation of constitutive glycoconjugate secretion in human skin fibroblasts; and 2) this process is impaired in CF disease.

Flanged acetabular components in cemented Charnley hip arthroplasty. Ten-year follow-up of 350 patients

A flanged socket was introduced by Sir John Charnley for use in his low-friction hip arthroplasty in 1976. Experimental evidence has suggested that the flange offers an advantage in terms of cement pressurisation at the time of implantation. We have reviewed 302 primary Charnley arthroplasties followed for 9 to 11 years to determine the effect of the flanged socket on the radiological appearance. The incidence of radiological demarcation at the cement-bone interface is significantly reduced in early radiographs after the use of a flanged socket, and the advantage is maintained in the long-term results.

Oncogene-mediated propagation of tracheal epithelial cells from two cystic fibrosis fetuses with different mutations. Characterization of CFT-1 and CFT-2 cells in culture

Primary tracheal epithelial cells obtained from two fetuses with cystic fibrosis (CF) were successfully transfected with a plasmid vector recombined with the large T oncogene of SV40. The resulting tracheal cells were propagated in culture for up to 25 passages and retained the mutations of the CF genes carried by the two fetuses, one heterozygous for the S549N and N1303K substitutions (CFT-1 cells), and the other homozygous for the most common deletion delta F508 (CFT-2 cells). The transfected cells: (a) expressed the SV40 large T oncogene, as determined by immunofluorescence and Northern blot analysis; (b) retained typical epithelial morphology, as assessed by the presence of microvilli, desmosomes, gap junctions, and cytokeratin expression; (c) were fully responsive to the cAMP-stimulating agents isoproterenol, forskolin and vasoactive intestinal peptide for cAMP production and PKA activation; (d) do not produce any tumour in the athymic nude mice; (e) were diploid and tetraploid with a normal chromosomal complement at early passages, and (f) exhibited the abnormal regulation of chloride conductance characteristic of CF. These results indicate that CFT-1 and CFT-2 cells constitute a suitable model for: (a) comparison of the maturation and function of the CFTR protein mutated in the two nucleotide-binding domains; (2) analysis of the biochemical defect in CF epithelial airway cells, (c) development of new therapeutic agents, and correction of the CF defect by gene replacement therapy in vitro.

[Cellular expression of CFTR in cystic fibrosis: defective cyclic AMP-dependent regulation of glycoconjugate secretion in cystic fibrosis fetal tracheal epithelial cells transfected by SV40 large T oncogene]

Epithelial tracheal cells isolated from two fetuses with cystic fibrosis (CF) and non-CF fetus (control) were transfected with a plasmid vector recombined with the large T oncogene of SV40. All transfected cells expressed SV40 antigen and exhibited an epithelial morphology (junctional complex, cytokeratins). CFT cells retained the mutations of the CF gene, one heterozygous for the S549N/N1303K substitutions (CFT-1 cells), the other homozygous for the deletion delta F508 (CFT-2 cells). Accordingly, these CFT cells exhibited the defective beta-adrenergic regulation of chloride conductance. We compared the responsiveness of control (NT-1 cells) and CF cells (CFT-1 and CFT-2 cells) to agonists of the protein kinase A (PKA)-dependent pathway for stimulation of glycoconjugate secretion. We show that the isoproterenol (10(-5) M) and forskolin (10(-5) M) markedly increased the cAMP content and the PKA activity of all three cell lines. In contrast, these effectors produced an increase in glycoconjugate secretion in control cells, but not in CFT-1 and CFT-2 cells. In conclusion, our results indicate that CFT cells do not respond to agonists of the PKA-dependent pathway for stimulation of both glycoconjugate secretion and chloride transport, which suggests the involvement of CFTR in these two processes.

Vasopressin-stimulated [3H]-inositol phosphate and [3H]-phosphatidylbutanol accumulation in A10 vascular smooth muscle cells

1. The characteristics of vasopressin-stimulated phosphatidylinositol 4,5 bisphosphate (PtdIns(4,5)P2) and phosphatidylcholine (PtdCh) hydrolysis were examined in A10 vascular smooth muscle cells (VSMC), by assessing the formation of [3H]-inositol phosphates ([3H]-IP) and the accumulation of the phospholipase D (PLD) specific product, [3H]-phosphatidylbutanol ([3H]-PtdBuOH). 2. Vasopressin ([Arg8]-VP) and a number of related analogues stimulated the accumulation of [3H]-IP and [3H]-PtdBuOH with similar EC50 values, generating the same rank order of potency for each response (Arg8-VP = vasotocin = Lys8-VP much greater than oxytocin). 3. Inhibition of vasopressin-stimulated [3H]-IP and [3H]-PtdBuOH accumulation by the V1a receptor antagonists, Des-Gly9[beta-mercapto-beta,beta,-cyclopentamethylene propionyl, O-Et-Tyr2,Val4,Arg8]-vasopressin generated similar IC50 values suggesting that both these responses are mediated through the activation of a single V1a receptor subtype. 4. The onset of vasopressin-stimulated inositol-1,4,5-trisphosphate (Ins(1,4,5)P3) mass formation preceded [3H]-PtdBuOH accumulation indicating that PtdCh hydrolysis was activated subsequent to PtdIns(4,5)P2 breakdown. 5. The protein kinase C (PKC) activator, tetradecanoylphorbol acetate (TPA) also stimulated [3H]-PtdBuOH accumulation. Preincubation with the PKC inhibitor Ro-31-8220 abolished both TPA- and vasopressin-stimulated [3H]-PtdBuOH, suggesting that the intermediate activation of protein kinase C is involved in the regulation of PLD by vasopressin. 6. Pretreatment of the A10 VSMC with Ro-31-8220 (100 microM) also potentiated vasopressin-stimulated Ins(1,4,5)P3 mass formation.Therefore stimulation of PKC may have opposing roles in the regulation of agonist activation of PLC and PLD.7. Preincubation of the cells with EGTA, verapamil, or the receptor-operated calcium channel antagonist, SK&F 96365, reduced vasopressin-stimulated [3H]-PtdBuOH accumulation by approximately 30%, suggesting that influx of calcium has a significant role to play in the regulation of vasopressinstimulated PLD activity.

[Transient total motor aphasia. A complication of an axillary brachial plexus block]

Hypo- and hypertension, arrhythmias, bradycardia extending to cardiac arrest with circulatory failure, pneumothorax, allergic reactions with or without anaphylactic shock, production of methaemoglobin, vomiting, vertigo, disorientation, acoustic and visual disorders, tinnitus, slurred speech, muscle contractions, unconsciousness, and epileptic seizures are well-known complications associated with local anaesthetics. We have observed an additional central nervous system complication: a case of transient, total motor aphasia (Broca aphasia) in a 50-year-old patient after axillary blockade of the brachial plexus. Possible causes such as type and dosage of local anaesthetic or a transient ischaemic attack in the area of the prerolandic artery are discussed and related to the literature. Ultimately, however, it is still not apparent why this complication could appear although there was no overdosage intravascular injection, or abnormality of the pulse or blood pressure, and why its manifestation was limited to a motor aphasia.

Hypersensitivity of diabetic human platelets to platelet activating factor

Platelet activating factor (PAF) stimulated aggregation and [32P]-phosphatidic acid (PA) production was compared in normal and diabetic human subjects in platelet rich plasma. The concentration of PAF for half maximal (50%) aggregation of normal and diabetic platelets was 50 nM and 8 nM, respectively. PAF stimulated [32P]-PA production (a metabolite of phospholipase C pathway) was also greater in the platelets from diabetic subjects. This [32P]-PA production was inhibited by the PAF receptor antagonists SRI-63441 and SRI-63675. When the levels of glycosylated hemoglobin (HbA1c) were compared with the PAF stimulated [32P]-PA production a significant relationship was observed. These studies have demonstrated for the first time that diabetic human platelets show hypersensitivity to PAF in both aggregation and [32P]-PA production compared to normal subjects. This may be a result of some modification in phospholipid turnover mechanism and is receptor mediated. Further, the relationship of the degree of aggregation and [32P]-PA production to the level of HbA1c suggest that the insulin deficiency may contribute to these effects.

Liposome immune lysis assay (LILA) for gelonin

A complement-mediated liposome immune lysis assay using entrapped calcein was developed for a plant toxin gelonin. Gelonin was covalently coupled to DPPE, and then adsorbed on to the surface of liposomes. Such antigen-bearing liposomes when incubated with anti-gelonin antibody in the presence of guinea pig complement undergo lysis. The detection range is from 3 ng to 60 ng. The method was used to monitor isolation of gelonin by affinity chromatography. It was observed that a minor peak in addition to the major one comes with gelonin, shared common epitopes/epitope with gelonin in immunological reaction. This was further confirmed by SDS-gel electrophoresis indicating the former being an isoform of gelonin. A comparative study of the immunocross-reactivity of ricin and ricin A chain with anti-gelonin antibody was carried out. It was found that while ricin A chain cross-reacted extensively with gelonin antibody and intact ricin elicited little or no cross-reactivity. It is suggested that the present LILA may be employed for the detection and quantitation of ricin A chain by this LILA method.

Two-dimensional crystallization of a bacterial surface protein on lipid vesicles under controlled conditions

The solubilized surface protein of the Gram-negative bacterium Comamonas acidovorans was reconstituted on lipid vesicles by means of controlled dialysis. To this end, a multichamber dialysis apparatus was built which allows one to control the temperature and the dialysis rate, to apply various temperatures or buffer systems and sample conditions in a single experiment, and to monitor the turbidity of the sample by means of light scattering. The reconstitution conditions were optimized such that the surface protein formed two-dimensional crystals suitable for electron crystallography. The recrystallized surface protein arrays gave a resolution of approximately 1.3 nm in projection after correlation averaging of negatively stained preparations. The surface protein assembled into partially self-contained two-dimensional crystals which possess a strong shape-determining effect and formed cylinders and various cone-shaped vesicles. The development of the various vesicle forms is described in a model.

The reversibility of impaired mucociliary function after lung transplantation

Impairment of mucociliary function occurs after lung transplantation and may predispose patients to repeated pulmonary infections. The purpose of this study is to determine whether and how soon such mucociliary function may recover. Ten dogs underwent left lung autotransplantation. Within 3 weeks five of these dogs underwent study for proximal airway clearance by observation through a bronchoscope of the movement of carbon particles placed at different locations on the tracheobronchial mucosa. The mechanical properties of collected mucus from specific sites were determined by magnetic rheometry. The right lung, which was not operated on, served as a paired control. Similar studies were conducted in the remaining five dogs at 12 weeks after autotransplantation. Lung autotransplantation caused significant depression of proximal airway clearance and a 35% increase in mucous rigidity (p = 0.05) soon after operation. At 12 weeks after operation, there was a partial recovery of proximal airway clearance. Mucous changes were no longer consistent. Histologic and electron microscopic examinations initially revealed focal denudation of ciliated cells and loss of the bronchial glands. At 12 weeks there was a regeneration of cilia and a reappearance of the bronchial glands. We conclude that the mucociliary function, observed to be depressed early after lung autotransplantation, recovers partially during the late postoperative period. Thus the mucociliary functional recovery should be attributed to revascularization rather than to reinnervation, since the latter is unlikely to occur during this period.

Regulation of secretion in cultured tracheal serous cells by protein kinases A and C

We recently reported that cultured gland serous cells release chondroitin sulfate proteoglycans (CSPGs) in response to beta-adrenergic agonists. In this study, we analyzed this regulatory pathway and other cellular mechanisms responsible for CSPG secretion. We show the following. 1) Isoproterenol increased CSPG secretion in a concentration-dependent manner, with maximal stimulation (50%) obtained at 10(-5) M; at this concentration, the beta-agonist also stimulated protein kinase A (PKA) by 50%, whereas it increased cellular adenosine 3',5'-cyclic monophosphate (cAMP) content by 300%. 2) Phenylephrine (10(-5) M), 4 beta-phorbol 12 beta-myristate 13 alpha-acetate (1.6 x 10(-7) M), and A23187 (10(-6) M) also stimulated CSPG secretion; this stimulation was concomitant with protein kinase C (PKC) translocation from cytosol to membrane, was blocked by sphingosine (2 x 10(-5) M), and was additive with that elicited by isoproterenol. 3) All PKC activators potentiated the isoproterenol-induced increased in cAMP accumulation without modifying the activation of PKA elicited by the beta-agonist. Our results indicate that although the signaling pathways triggered by alpha- and beta-adrenergic agonists converge at the level of adenylate cyclase in tracheal serous cells, PKA and PKC independently regulate CSPG secretion.

[Dyspepsia and food intolerance in symptomatic gallstone disease. Does cholecystectomy help?]

60 patients with symptomatic gallstone disease were asked about their abdominal symptoms and food intolerance. Equally a healthy control group was investigated. Preoperatively, 72% of patients with gallstones suffered from right upper quadrant pain. Additionally all patients complained of associated dyspeptic symptoms (100% vs. 8% of the control group). 51% of patients with gallstone disease vs. 15% of the control group avoided flatulent and fatty food. 4 months after cholecystectomy, 90% were painfree, 82% were free of dyspeptic symptoms and 84% were not complaining of any food intolerance. 6% developed new food intolerances. Thus cholecystectomy seems to be an effective treatment, not only for typical gallstone related symptoms, but also for associated symptoms, such as dyspepsia and food intolerance. Different therapeutic regimens have to compete with these results.

Pericellular glycoconjugates of cultured fibroblasts from control and cystic fibrosis patients

1. Labeled glycoconjugates released by trypsin from cell surfaces of control and cystic fibrosis (CF) skin fibroblasts were purified and fractionated by column chromatography on Sephadex G-50 and Concanavalin A Sepharose. Based on chemical analysis and specific enzymatic digestions: (1) Glycoconjugates were characterized as O-linked glycopeptides consisting predominantly of glycosaminoglycan type and N-linked glycopeptides with glycans of complex type. Their relative proportions were similar between the two groups. (2) The N-linked glycopeptides exhibited an increased molar ratio of fucose to galactose in CF fibroblasts. (3) When pericellular glycoconjugates were metabolically labeled with [14C]glucosamine and [3H]fucose, incorporation and degradation kinetics were similar between the two groups.

Further evidence for abnormal protein kinase C regulation of macromolecule secretion in fibroblasts from cystic fibrosis patients

In comparison to skin fibroblasts from normal subjects, those from patients with cystic fibrosis (CF): (1) bound [20-3H] phorbol 12,13-dibutyrate (PDBu) with a higher affinity Kd = 25.8 vs 12.8 nM respectively) but expressed a similar number of total phorbol ester binding sites (about 2.5 pmol PDBu bound/mg of protein); (2) exhibited a faster and higher response to 4 beta-phorbol 12 beta-myristate 13 alpha-acetate (PMA) for the stimulation of [35S]-labelled glycoconjugate release, but were equally sensitive to the synergistic effect of A23187 on this process; and (3) secreted glycoconjugates with similar [35S]-sulfate and [14C]-leucine to [14C]-glucosamine labelling ratios. Taken together, these results provide further evidence for abnormal protein kinase C (PKC) regulation of macromolecule secretion in CF disease.

Fimbrial phase variation in Bordetella pertussis: a novel mechanism for transcriptional regulation

Fimbriae belong to a class of extracellular filamentous proteins which are involved in the attachment of bacteria to host tissues. Bordetella pertussis, the etiological agent of whooping cough, produces two serologically distinct fimbriae. We show that, like a number of other B. pertussis virulence genes, transcription of the fimbrial subunit genes (fim) is positively controlled by trans-acting polypeptides encoded by the bvg locus. In addition to this coordinate control, transcription of the fim genes is regulated at an individual level by phase variation. This process is characterized by a switching between a high and low level of expression of a particular fim gene. We have identified a conserved DNA region, located close to the start of the fim genes, which is likely to be involved in both positive regulation by the bvg locus, and phase variation. This promoter region contains a stretch of approximately 15 C residues and it appears that phase transitions occur by small insertions or deletions in this C-rich region. We propose that these mutations affect transcription of the fim genes by varying the distance between the binding site for an activator and the -10 box. The fim promoter shows homology with the pertussis toxin promoter, which is also positively regulated by the bvg locus.

Endoscopic guided percutaneous tracheostomy: early results of a consecutive trial

Percutaneous tracheostomy is increasingly being used for patients needing prolonged ventilatory support. The purpose of this study was to assess the feasibility of widespread application of endoscopic guided percutaneous tracheostomy. Sixty-one consecutive ICU patients requiring prolonged mechanical ventilation underwent bedside endoscopic guided percutaneous tracheostomy. Using a modified Ciaglia technique, a #6-10 tracheostomy tube was introduced between the second and third tracheal rings. Bronchoscopic transillumination facilitated identification of the appropriate tracheostomy site, and verified satisfactory placement of dilators and tracheostomy tube. There was one procedure-related death due to arrhythmia. Procedure-related complications included (n = 7): bleeding (controlled with local pressure), two infections, two cuff tears, and two obstructions of the tracheal tube. The tracheostomy was eventually removed in 13 patients. Bronchoscopic evaluation of three patients at 4 months post-tracheostomy removal was normal and there has been no clinical evidence suggestive of tracheal stenosis in the remaining ten extubated patients. There was a 50% reduction in cost when compared to operative tracheostomy. Percutaneous tracheostomy is a simple, safe, cost-effective bedside procedure for critically ill ventilator-dependent patients. Endoscopic guidance appears to increase the safety of this procedure and may prevent complications of pneumothorax, subcutaneous emphysema, and paratracheal false passage previously reported with blinded percutaneous methods.

Does the addition of albumin to the prime solution in cardiopulmonary bypass affect clinical outcome? A prospective randomized study

Colloid solution is commonly used to increase the oncotic pressures of priming solutions used in the cardiopulmonary bypass circuit. To study the effectiveness of this practice, we prospectively randomized 100 adult patients undergoing cardiac operations to receive Ringer's lactate solution plus 50 gm of albumin (group A) or Ringer's lactate solution alone (group B) as the prime solution for the bypass circuit. Personnel involved in the management of these patients were blinded concerning the group to which the patients had been randomized. Forty clinical parameters related to perioperative fluid balance, cardiopulmonary function, and renal function were studied. Although group B received a larger volume of crystalloid solution intraoperatively (p less than 0.05), had a lower mean cardiac filling pressure (p less than 0.05), and had a higher hematocrit value (p less than 0.05) in the immediate postoperative period, all mean values for both groups were within the normal range. There were no differences between the two groups with regard to postoperative clinical parameters of cardiopulmonary and renal function, nor was outcome affected by the addition of albumin to the prime solution. We conclude that there is no clinically detectable advantage for the practice of adding 50 gm of albumin to the priming solution of bypass circuits in adults undergoing cardiac operations. Routinely supplementing the bypass prime solution with albumin adds significant cost, estimated to be approximately $10,000 per 100 cases, without demonstrable clinical benefits. Whether this practice can be of value in selected cases needs to be further studied.

Mucociliary function in autotransplanted, allotransplanted, and sleeve resected lungs

Tracheobronchial mucociliary function in dogs that underwent left upper sleeve lobectomy was compared with that of dogs that underwent left lung autotransplantation or allotransplantation (n = 5 each). Proximal airway clearance was measured by observing the movement of carbon particles through a bronchoscope. Preoperative and postoperative clearance rates for the right lungs in these dogs were unchanged. Although preoperative clearance rates in the transplanted left lungs were comparable with those of the right lungs, these left lungs were unable to clear the carbon particles during a 15-minute observation period 3 weeks postoperatively. In contrast, preoperative and postoperative clearance rates for the dogs that underwent sleeve resection were unchanged for both lungs. Mucus rigidity was studied by microrheometry and was found to be significantly increased postoperatively for samples collected from the autotransplanted and allotransplanted lungs than for samples collected from the untreated right lungs. These changes in mucus were noted for forces representing both normal ciliary beat and coughing. Viscoelastic properties of mucus were not significantly altered after sleeve lobectomy. Microscopic study showed squamous cell metaplasia and relative disappearance of bronchial glands distal to the anastomosis in all transplanted lungs. These changes were less pronounced in the sleeve resected bronchi. We conclude that changes in rheologic characteristics of mucus can impair mucociliary clearance and may be related to denervation after lung transplantation. Bronchial devascularization may have an additional effect of altering mucosal structures and function in the early postoperative period after lung transplantation. These effects are avoided by preserving peribronchial tissue in sleeve resection.

Atypical lymphoid hyperplasia (lymphoid tumour of indeterminate nature) of orbit--a case report

Atypical lymphoid hyperplasia, a rare variety of orbital tumour occurring in a 60 year old male patient is presented with review of literature with special relation to its diagnostic and prognostic difficulties.

Does the surgical trauma of "exploratory thoracotomy" affect survival of patients with bronchogenic carcinoma?

A retrospective review was carried out to assess the possible adverse immunosuppressive effect of exploratory thoracotomy on the survival of patients with non-small cell carcinoma of the lung with N2 nodal metastases. Between 1960 and 1982, 48 patients with non-small cell bronchogenic carcinoma underwent exploratory thoracotomy; lung resection was not done because mediastinal lymph nodes were involved. The survival of these patients was compared with that of 64 patients in whom N2 disease was established by mediastinoscopy alone and who did not undergo thoracotomy. There were no significant differences with respect to age, sex, tumour type and adjunctive radiotherapy. There were slightly more T4 tumours in the thoracotomy group (50% versus 30%). The hospital stay was longer in the thoracotomy group (2.3 +/- 1.1 versus 1.5 +/- 0.9 months [mean +/- SD]). However, follow-up studies showed that, although these patients had a more traumatic procedure, the actuarial survival curves for the two groups were virtually identical, and the 12-month survival rates were less than 20% for both groups. The median survival was 6.0 months for the thoracotomy group and 7.0 months for the mediastinoscopy group. These findings failed to demonstrate an adverse immunosuppressive effect of thoracotomy on lung cancer patients.

Percutaneous endoscopic tracheostomy

Bedside percutaneous tracheostomies are increasingly performed. This avoids patient transport to the operating room. Complications of this procedure are largely related to the blind nature of the technique. After laboratory studies, 4 patients underwent percutaneous endoscopic guided tracheostomy in a selective clinical trial. There were no procedure-related complications. Endoscopic guidance ensures precise low tracheostomy position, prevents paratracheal tube misplacement, and avoids inadvertent injuries.

Phorbol ester-induced protein kinase C translocation and lysosomal enzyme release in normal and cystic fibrosis fibroblasts

The ability of the tumor-promoting phorbol ester 4 beta-phorbol 12 beta-myristate 13 alpha-acetate (PMA) to induce protein kinase C (PKC) translocation and lysosomal enzyme release was examined in skin fibroblasts from normal subjects and from patients with cystic fibrosis (CF). As compared to normal fibroblasts, those CF exhibited: (i) an increased sensitivity to the effect of PMA on the disappearance of PKC from cytosolic fractions as well as a greater and earlier recovery, in the membrane fraction, of the PKC activity lost in the cytosolic fraction; (ii) an earlier response to PMA for its effect on beta-N-acetylglucosaminidase release. In contrast, the inactive phorbol ester 4 alpha-phorbol 12,13-didecanoate (4 alpha PDD) proved ineffective in inducing PKC translocation and beta-N-acetylglucosaminidase release in both normal and CF fibroblasts. The data suggest a defect in the regulation of PKC activity in CF fibroblasts, which may lead to altered secretion.

Rank relations of juvenile and subadult natal males of Barbary macaques (Macaca sylvanus) at Affenberg Salem

Rank relations of more than 100 juvenile and subadult natal Barbary macaque males were analyzed. Hierarchical relations among individuals of the same age were established early during the first year of life. With few exceptions concerning infants from very high-ranking genealogies, males dominated female peers regardless of maternal rank. Males started to outrank females from older cohorts during the second year of life and completed the process of rank reversal with adult females at 5-6 years of age. An age-graded dominance pattern existed among males from different birth cohorts. Only 3 rank reversals between males from different cohorts were observed. Rank reversals among males of the same birth cohort occurred more frequently. Rank position of a male among his male peers was influenced by birth order, by maternal rank, and by the presence of juvenile brothers. Most males without juvenile brothers had low positions, regardless of maternal rank. Males born late in the birth season were also low-ranking, even when juvenile brothers were present. There was no cohort where ranking among males was determined by maternal rank alone, as is the case in rhesus monkeys and Japanese macaques. Adult/subadult male carriers had no noticeable effect on rank positions of 'their' infants. It is suggested that a weaker influence of Barbary macaque mothers on rank of their sons is related to very early integration of male infants in male social/play groups.