Role of routine oesophago-gastroduodenoscopy before cholecystectomy

INTRODUCTION

A proportion of patients do not get symptomatic relief after cholecystectomy because there is an overlap in the symptomology of biliary and gasroduodenal pathologies. In our unit all the patients are offered gastroscopy prior to Cholecystectomy. Aim of this study was to evaluate the efficacy of gastroscopy in all patients with upper abdominal pain irrespective of ultrasound findings.

MATERIAL AND METHODS

This retrospective study was carried out, between Jan 2001-Oct 2003. All the patients undergoing laparoscopic cholecystectomy by a single surgeon were studied. Group 1 (n = 61) were not endoscoped before the operation (Jan 2001-May 2002). Group 2 (n = 60) had routine endoscopy carried out before surgery (June 2002-October 2003). The results were entered in a database and analyzed.

RESULTS

Total of 240 laparoscopic cholecystectomies were carried out. Female to male ratio was 4:1. In Group 1, the recurrence or persistence of symptoms was 20/61 (32.78%) patients who were not scoped. In Group 2, all patients were scoped with positive findings in 35% of the patients. All were treated for the pathology and only 2(3.3%) had recurrence or persistence of symptoms.

CONCLUSION

The routine use of gastroscopy before laparoscopic cholecystectomy helps to reduce persistence of symptoms and is recommended.

An analysis of renal dysfunction in 1511 patients with fractured neck of femur: the implications for peri-operative analgesia

SUMMARY

Following two deaths from respiratory failure secondary to opioid toxicity in patients admitted for surgical repair of fractured neck of femur, we retrospectively studied the serum urea and electrolyte concentrations of 1511 consecutive patients requiring surgery for proximal femoral fracture, and calculated their glomerular filtration rate. Five hundred and forty-five (36.1%) patients had renal dysfunction on admission (glomerular filtration rate < 60 ml x min(-1).1.73 m(-2)); 435 (28.8%) had grade 3 chronic kidney disease (moderate; glomerular filtration rate 30-59 ml x min(-1).1.73 m(-2)), 82 (5.4%) had grade 4 disease (severe; glomerular filtration rate 15-29 ml x min(-1).1.73 m(-2)) and 28 (1.9%) had grade 5 (renal failure; glomerular filtration rate < 15 ml min(-1).1.73 m(-2)). The 30-day mortality for patients with renal dysfunction (62/536; 11.6%) was significantly greater (p = 0.004) than for patients with normal renal function (68/958; 7.1%), although median (IQR [range]) postoperative lengths of stay were similar 15 (10-22 [1-125]) vs 14 (9-22 [1-120]) days respectively; p = 0.06). Renal impairment is common in patients admitted for fixation of fractured neck of femur, who are consequently at risk of opioid toxicity.

Crystallization and preliminary X-ray diffraction analysis of L-threonine dehydrogenase (TDH) from the hyperthermophilic archaeon Thermococcus kodakaraensis

The enzyme L-threonine dehydrogenase catalyses the NAD(+)-dependent conversion of L-threonine to 2-amino-3-ketobutyrate, which is the first reaction of a two-step biochemical pathway involved in the metabolism of threonine to glycine. Here, the crystallization and preliminary crystallographic analysis of L-threonine dehydrogenase (Tk-TDH) from the hyperthermophilic organism Thermococcus kodakaraensis KOD1 is reported. This threonine dehydrogenase consists of 350 amino acids, with a molecular weight of 38 kDa, and was prepared using an Escherichia coli expression system. The purified native protein was crystallized using the hanging-drop vapour-diffusion method and crystals grew in the tetragonal space group P4(3)2(1)2, with unit-cell parameters a = b = 124.5, c = 271.1 A. Diffraction data were collected to 2.6 A resolution and preliminary analysis indicates that there are four molecules in the asymmetric unit of the crystal.

Medically Unexplained Myopathy Due to Ipecac Abuse

The use of ipecac, once recommended as an emetic for use in toxic ingestions, has more recently been discouraged for use in home and emergency room settings. It remains readily available, and has been associated with abuse in eating disorders and Munchausen syndrome by proxy. This case discusses an adolescent boy who surreptitiously abused ipecac in the context of distress over parental conflict, and the extensive medical workup undertaken to evaluate unexplained symptoms of proximal muscle weakness, abdominal pain, and, eventually, cardiomyopathy that are sequelae of ipecac toxicity. Clinicians should be alerted to ipecac ingestion with similar presentation.

Surface charge and the effect of excess calcium ions on the hydroxyapatite surface

This paper describes the use of surface titration as a more direct probe of the surface chemistry of hydroxyapatite (HA) than zeta-potential measurements. The variation in HA surface charge with pH for two different KCl electrolyte concentrations was determined titrimetrically and the point of zero charge (PZC) found to be at a pH of 7.3 +/- 0.1. The curves also demonstrated that HA accumulates positive charge more readily below the PZC than it accumulates negative charge above it. Extended titration data indicated that dissolution occurred more rapidly in increasingly acidic conditions, but was inhibited by increasing electrolyte strength. Similar experiments with 2.5 mM Ca(2+) in the electrolyte show that Ca(2+) adsorption balances loss of H(+) to give a near-neutral surface at any pH above 7 (subject to availability of calcium ions and adsorption sites). The mechanism for adsorption has been shown to be deprotonation of adjacent surface HPO(4)(2-) sites and subsequent adsorption of a calcium ion to the lattice surface site. Furthermore, inhibition of dissolution under alkaline conditions in the presence of Ca(2+) suggested that dissolution was driven by desorption of Ca(2+). Modelling of the adsorption/desorption processes demonstrated that in both pure water and under physiological conditions phosphate groups will predominate at the HA surface. Furthermore, the (200) plane was identified as the likely form of the HA surface. These methodologies and findings are particularly relevant to investigation of biological response with respect to modification of surface hydrophobicity and surface energy or charge.

Isolation and characterization of psychrotrophs from subterranean environments

Subterranean environments are potential sources for the isolation of novel microorganisms. Water and soil samples were collected at depths ranging from 10 to 1800 meters below the surface, and screening was carried out with aerobic rich and anaerobic minimal media. Two psychrotrophic and three chemoautotrophic strains were isolated. One of the psychrotrophic isolates, designated SN16A, grew at temperatures between -5 and 37 degrees C with optimal growth between 25 and 30 degrees C. The other psychrotroph, designated KB700A, grew between -10 and 30 degrees C. Little difference in growth rate could be observed between 20 and 30 degrees C; however, this strain did not grow at 37 degrees C. KB700A utilized CO2 chemoautotrophically at 30 degrees C, using hydrogen as an energy source. Both strains were characterized biochemically. The complete 16S rRNA sequence of KB700A was 98.7% homologous with that of Pseudomonas marginalis. However, the 16S rRNA of SN16A showed only 95.4% identity at maximum-with the corresponding gene of Arthrobacter globiformis-suggesting that this strain may belong to a novel genus. Both strains exhibited the ability to produce hydrolytic enzymes on plate assays. Our results suggest that subterranean environments are promising sources for the isolation of psychrotrophic microorganisms.

Successful treatment of a patient with mixed warm and cold antibody mediated Evans syndrome and glucose intolerance

Thrombocytopenia and autoimmune hemolytic anemia (Evans syndrome) with the presence of both warm and cold autoantibodies (mixed type) are rare in the pediatric age group. This condition may be associated with other autoimmune disorders and is notoriously difficult to treat. This case describes an adolescent male who presented with rapid onset Evans syndrome and diabetes. After failing to respond to high dose prednisone and intravenous immunoglobulin, the patient was successfully treated with monoclonal antibody against CD20 (anti-CD20). This suggests that anti-CD20 is a valuable treatment for severe warm and cold antibody mediated Evans syndrome, and possibly for select cases of antibody mediated diabetes.

Interface of Women's Mental and Reproductive Health

The interface of women's reproductive and mental health is an evolving area of psychiatric practice, necessitating familiarity with psychobiological factors unique to women. The role of estrogen in particular has profound implications for the etiology and treatment of women's psychiatric illness, and has been reviewed along with the role of other hormones. Additionally, the stress of specific life events such as miscarriage, abortion, and menopause affects female mental health from a biological and psychosocial standpoint with the potential for secondary mood and anxiety disorders. Psychiatric issues during pregnancy and the postpartum period present special diagnostic and treatment challenges to the clinician. Biological and psychosocial treatments of these conditions have been reviewed. Management of psychiatric conditions during pregnancy and the postpartum period should include the obstetrician, pediatrician, and involved family members. Treatment decisions should involve careful assessment of the risks and benefits of any intervention including the risk of no treatment.

Closure of aortopulmonary window with amplatzer duct occluder device

Aortopulmonary window is a relatively uncommon congenital heart defect. We report on a patient with a small aortopulmonary window, who presented with an asymptomatic murmur and in whom catheter closure was successfully performed with an Amplatzer Duct Occluder.

Low-temperature lipase from psychrotrophic Pseudomonas sp. strain KB700A

We have previously reported that a psychrotrophic bacterium, Pseudomonas sp. strain KB700A, which displays sigmoidal growth even at -5 degrees C, produced a lipase. A genomic DNA library of strain KB700A was introduced into Escherichia coli TG1, and screening on tributyrin-containing agar plates led to the isolation of the lipase gene. Sequence analysis revealed an open reading frame (KB-lip) consisting of 1,422 nucleotides that encoded a protein (KB-Lip) of 474 amino acids with a molecular mass of 49,924 Da. KB-Lip showed 90% identity with the lipase from Pseudomonas fluorescens and was found to be a member of Subfamily I.3 lipase. Gene expression and purification of the recombinant protein were performed. KB-Lip displayed high lipase activity in the presence of Ca2+. Addition of EDTA completely abolished lipase activity, indicating that KB-Lip was a Ca2+-dependent lipase. Addition of Mn2+ and Sr2+ also led to enhancement of lipase activity but to a much lower extent than that produced by Ca2+. The optimal pH of KB-Lip was 8 to 8.5. The addition of detergents enhanced the enzyme activity. When p-nitrophenyl esters and triglyceride substrates of various chain-lengths were examined, the lipase displayed highest activity towards C10 acyl groups. We also determined the positional specificity and found that the activity was 20-fold higher toward the 1(3) position than toward the 2 position. The optimal temperature for KB-Lip was 35 degrees C, lower than that for any previously reported Subfamily I.3 lipase. The enzyme was also thermolabile compared to these lipases. Furthermore, KB-Lip displayed higher levels of activity at low temperatures than did other enzymes from Subfamily I.3, indicating that KB-Lip has evolved to function in cold environments, in accordance with the temperature range for growth of its psychrotrophic host, strain KB700A.

A new suture for hair transplantation: poliglecaprone 25

BACKGROUND

The most common type of donor closure in hair transplantation is with nonabsorbable, running sutures, usually of nylon or polypropylene. This is accomplished with or without buried absorbable sutures. Another popular method of closure is with stainless steel staples. Each of these methods has benefits and limitations with respect to healing, comfort, and convenience for the patient.

OBJECTIVE

The purpose of this study is to describe the use of poliglecaprone 25, a synthetic, absorbable, monofilament suture in hair transplantation surgery, to detail the suturing techniques needed to maximize the benefit of this suture, and to compare this material and suturing technique to a well-established form of closure, that of metal staples in a bilaterally controlled fashion.

METHODS

Poliglecaprone 25 is a synthetic, absorbable monofilament suture of low tissue reactivity. It was compared to closure with metal staples in a bilateral controlled study. One side of the donor area was closed with poliglecaprone 25 sutures using a running cutaneous stitch and the other side was closed with stainless steel staples. Patients were evaluated with regard to healing, postoperative discomfort, resultant surgical scar, and closure material preference.

RESULTS

Of the 22 patients studied, the following postoperative complaints were noted on the staples side: tenderness (12), itching (4), swelling (2), and scabbing (1). This compared to only one complaint of itching and one complaint of swelling on the poliglecaprone 25 side. Two patients had postoperative complaints of visibility of staples showing through their hair. Objective measurements revealed a wider scar overall on the staples side in six patients and wider scar on the suture side in two patients. The average scar width on the staples side measured 1.78 mm compared to 1.42 mm on the suture side. Fourteen of the 22 patients preferred poliglecaprone 25 for future procedures, 1 preferred metal staples, and 7 had no preference. Most patients stated that postoperative discomfort from the staples and the inconvenience and occasional pain associated with their removal was responsible for their decision.

CONCLUSION

Poliglecaprone 25 is a strong synthetic, absorbable, monofilament suture with low tissue reactivity that can be used in hair transplantation to close the donor wound with a single, running cutaneous stitch. This suture can provide a donor closure that ensures hemostasis, has little risk of infection, and is comfortable for the patient. If specific surgical techniques are followed, this suture can provide a donor closure that ensures hemostasis has little risk of complications, is both comfortable and convenient for the patient postoperatively and results in a fine surgical scar.

Crystallization and preliminary X-ray study of Pk--REC from a hyperthermophilic archaeon, Pyrococcus kodakaraensis KOD1

Pk-REC is a protein which binds to DNA and catalyzes the central step of recombination and repair. The protein was crystallized using the hanging-drop vapour-diffusion method with PEG as a precipitant. Two orthorhombic crystal forms I and II with the same space group P2(1)2(1)2(1) were obtained at pH 8.0 using PEG 3000 and PEG 550 monomethylether, respectively. The unit-cell parameters were a = 151, b = 174, c = 241 A for form I and a = 151, b = 176, c = 300 A for form II, indicating that the asymmetric unit contains more than 20 molecules.

A unique DNase activity shares the active site with ATPase activity of the RecA/Rad51 homologue (Pk-REC) from a hyperthermophilic archaeon

A RecA/Rad51 homologue from Pyrococcus kodakaraensis KOD1 (Pk-REC) is the smallest protein among various RecA/Rad51 homologues. Nevertheless, Pk-Rec is a super multifunctional protein and shows a deoxyribonuclease activity. This deoxyribonuclease activity was inhibited by 3 mM or more ATP, suggesting that the catalytic centers of the ATPase and deoxyribonuclease activities are overlapped. To examine whether these two enzymatic activities share the same active site, a number of site-directed mutations were introduced into Pk-REC and the ATPase and deoxyribonuclease activities of the mutant proteins were determined. The mutant enzyme in which double mutations Lys-33 to Ala and Thr-34 to Ala were introduced, fully lost both of these activities, indicating that Lys-33 and/or Thr-34 are important for both ATPase and deoxyribonuclease activities. The mutation of Asp-112 to Ala slightly and almost equally reduced both ATPase and deoxyribonuclease activities. In addition, the mutation of Glu-54 to Gln did not seriously affect the ATPase, deoxyribonuclease, and UV tolerant activities. These results strongly suggest that the active sites of the ATPase and deoxyribonuclease activities of Pk-REC are common. It is noted that unlike Glu-96 in Escherichia coli RecA, which has been proposed to be a catalytic residue for the ATPase activity, the corresponding residual Glu-54 in Pk-REC is not involved in the catalytic function of the protein.

Median lip fissures and their management

Median lip fissures are an uncommon condition and usually give rise to pain and episodes of bleeding. We report three cases of median lip fissures which were treated by surgical excision.

Oral self-mutilation by a 17-month-old child with Lesch-Nyhan syndrome

We report a 17-month-old boy who was a known case of Lesch-Nyhan syndrome and presented with self-inflicted oral ulcerations of his lips and cheeks. He had a normal complement of caries-free deciduous teeth. Initially a conservative approach was planned and a bite plate made, but as a result of poor compliance and persistent ulceration and after consultation with his parents it was decided to extract all deciduous teeth.

Intermittent mental paraesthesia in an edentulous mandible

A patient presenting with bilateral intermittent mental paraesthesia on wearing a lower denture on a very atrophic ridge was treated with an implant-retained overdenture which resolved her symptoms.

Characterization of a RecA/RAD51 homologue from the hyperthermophilic archaeon Pyrococcus sp. KOD1

The Pk-rec gene, encoding a RecA/RAD51 homologue from the hyperthermophilic archaeon Pyrococcussp. KOD1, was expressed in Escherichia coli. The recombinant Pk-REC was purified to homogeneity and was shown to be in a dimeric form. A striking property of the purified recombinant Pk-REC was the unusual DNase activity on both single- and double-stranded DNAs along with the ATPase activity. The reaction product of this DNase activity was mononucleotides. The optimum temperature and pH for the DNase activity were 60 degrees C and 8-8.5, respectively. In addition, the metal ion requirement for DNase activity was different from that for the ATPase activity. The protein exhibited no DNase activity in the presence of Zn2+ion, which was one of the most preferable divalent cations for ATPase activity. Another unique characteristic of the recombinant protein was that the reaction product of ATPase activity was AMP instead of ADP.Pk-REC may represent a common prototype of the RecA family proteins with high RecA-like activity.

A RecA/RAD51 homologue from a hyperthermophilic archaeon retains the major RecA domain only

A gene encoding a RecA/RAD51 homologue from a hyperthermophilic archaeon, Pyrococcus sp. KOD1 (Pk), was cloned, sequenced and expressed in Escherichia coli. The deduced 210-amino acid sequence was compared to homologues from bacteria (RecA), eukaryotes (RAD51, DMC1) and archaea (RadA). The entire protein from Pk (Pk-REC) basically corresponds to the essential central domain of its counterparts and lacks the two smaller RecA subdomains at the N- and C-termini. The sequence comparison suggests that Pk-REC represents a common prototype of RecA, RAD51, DMC1 and RadA, with higher enzymatic activity. Recombinant Pk-REC was fully active and complemented the ultraviolet light sensitivity of an E. coli recA mutant strain.