ASA status and age predict adverse events after abdominal surgery

The objective of this study was to evaluate the ability of age and the American Society of Anesthesiologists (ASA) score to act as clinical indicators and predict clinical adversity after abdominal surgery. We evaluated 2570 patients who underwent abdominal surgery. The data were collected in a prospective manner with an unbiased measurement of the baseline risk and endpoint criteria. Age > 60 years and/or an ASA score > 2 identified over 80% of the patients who had a prolonged stay in hospital, developed intraperitoneal sepsis, were admitted to the ICU or died. This effect was additive which implies a useful degree of independence between the two risk factors. Age and the ASA score are useful indicators of clinical adversity and resource utilization after abdominal surgery. Hence, they can be used to benchmark the outcome of abdominal surgery between institutions.

Respiratory insufficiency after abdominal surgery

The objective of this study was to define the relationship between respiratory insufficiency (RI) and various putative risk factors for patients undergoing abdominal surgery. A review of 1332 adults undergoing abdominal surgery was undertaken. Information was collected in a unbiased, prospective and uniform manner with regard to baseline characteristics, perioperative events and adverse outcomes after surgery. Respiratory Insufficiency was defined as either: a PO2 < 60 mm Hg, the performance of a tracheotomy, or endotracheal intubation for more than 24 h. The incidence of RI was 3% (40/1332). A logistic regression analysis only identified an American Society of Anesthesia (ASA) classification > 2 (P < 0.001) and the presence of chronic bronchitis (P (P < 0.05) as significant risk factors. In addition, 33% (8/24) of the patients who developed postoperative intraperitoneal sepsis and 30% (14/47) of the patients who underwent a reoperation developed RI. It was concluded that patients with a significant systemic disease (ASA > 2), as well as patients with chronic bronchitis, should be the recipients of intense efforts to prevent pulmonary complications after abdominal surgery.

The quality of life of patients on a waiting list for transurethral resection of the prostate

We evaluated the quality of life of 50 patients with benign prostatic hypertrophy on a waiting list for transurethral resection of the prostate. The patients had a median age of 68 years (range: 48-84 years) and had been on the waiting list for a median of eight months (range: 2-36 months). Patients were assessed using the Benign Prostatic Hypertrophy Health-Related Quality of Life Survey Questionnaire. All patients had disagreeable urinary symptoms that interfered with their normal activities, for example, 92% of patients were troubled by disturbed sleep. The patients also had worries about the possibility of prostatic cancer (40%) and a perceived deterioration in sexual performance during the preceding year (56%). Eleven of the 14 patients who were re-evaluated one year after a transurethral resection of the prostate were completely free of any bothersome urinary symptoms.

White blood cell counts in patients undergoing abdominal surgery

BACKGROUND

The role of pre-operative white blood cell counts (WBCC) in patients with an acute abdomen is contentious.

METHODS

This study documents the association between pre-operative WBCC and the extent of intraperitoneal inflammation at the time of surgery in a heterogeneous group of 1166 patients undergoing abdominal surgery.

RESULTS

WBCC failed to adequately discriminate between groups of patients with varying degrees of intraperitoneal inflammation. For example, only 31% (37/118) of the patients with either free pus or an abscess within the peritoneal cavity had a WBCC > 15.0 x 10(9)/L.

CONCLUSIONS

There is a need to replace the WBCC with more powerful predictors of inflammation within the peritoneal cavity.

Evaluation of a wound scoring method for patients undergoing cardiac surgery

The main endpoint of studies evaluating antimicrobial prophylaxis in surgical patients is wound morbidity. This should consist of more than the solitary declaration of the rate of wound infection. In this study, a modified version of ASEPSIS (a wound scoring system) has been prospectively evaluated in 1000 patients undergoing cardiac surgery. Twenty-one patients (2.1%) had an infected sternal wound. The components of ASEPSIS most significantly associated with a sternal wound infection were: the presence of a purulent exudate, a postoperative stay > 14 days, the identification of pathogenic organisms, and the use of antibiotics (P < 0.0001). Although ASEPSIS is a useful mechanism for conveying information about wounds, it does ignore bleeding into wounds and the extent that troublesome wounds need to be dressed after surgery.

Courtship anomalies caused by doublesex mutations in Drosophila melanogaster

The role played by the sex-determining gene doublesex (dsx) and its influence on Drosophila courtship were examined. Against a background of subnormal male-like behavior that is reported to be an attribute of haplo-X flies homozygous for the original dsx mutation, and given that a sex-specific muscle is unaffected by genetic variation at this locus, analyses of several reproductive behaviors and control for genetic background effects indicated that XY dsx mutants are impaired in their willingness to court females. When they did court, certain behavioral actions were normal, including components of courtship song. However, these mutants never produced courtship humming sounds. Mature XY dsx flies elicited anomalously high levels of courtship; that this occurs merely because of a delay in imaginal development was experimentally discounted. The current analysis reconciled two ostensibly conflicting reports involving the courtship-stimulating qualities of this mutant type. Such experiments also uncovered a new behavioral anomaly: dsx mutations caused chromosomal males to court other males at abnormally high levels. These results are discussed from the perspective of doublesex's influence on internal tissues of adult Drosophila involved in the triggering and neural control of male- and female-like elements of courtship, reproductive pheromone production, or a combination of such factors.

Bioassaying putative RNA-binding motifs in a protein encoded by a gene that influences courtship and visually mediated behavior in Drosophila: in vitro mutagenesis of nonA

The no-on-transient-A (nonA) gene of Drosophila melanogaster influences vision, courtship song, and viability. The nonA-encoded polypeptide is inferred to bind single-stranded nucleic acids. Although sequence-analysis of NONA implies that it belongs to a special interspecific family of this protein type, it does contain two classical RNA recognition motifs (RRM). Their behavioral significance was assayed by generating transgenic strains that were singly or multiply mutated within the relatively N-terminal motif (RRM1) or within RRM2. Neither class of mutation affected NONA binding to polytene chromosomes. The former mutations led to extremely low viability, accompanied by diminished adult longevities that were much worse than for a nonA-null mutant, implying that faulty interpolypeptide interactions might accompany the effects of the amino-acid substitutions within RRM1. All in vitro-mutated types caused optomotor blindness and an absence of transient spikes in the electroretinogram. Courtship analysis discriminated between the effects of the mutations: the RRM2-mutated type generated song pulses and trains that tended to be mildly mutant. These phenotypic abnormalities reinforce the notion that nonA's ubiquitous expression has its most important consequences in the optic lobes, the thoracic ganglia, or both, depending in part on the nonA allele.

Methodologic standards in surgical trials

BACKGROUND

Concerns have been raised that flaws in the design and analysis of trials will hinder the interpretation of their relevance to clinical practice. The objective of this study was to review the nature and methodologic standards of surgical trails published in 10 prestigious journals between January 1988 and December 1994.

METHODS

We evaluated the demography and methodologic standards of 364 trials. Each article was independently scrutinized by two assessors with documentation of the interassessor variation.

RESULTS

Less than 50% of the trials made comment about an unbiased assessment of outcome, gave an adequate description of the randomization technique, or provided a prospective estimate of the sample size. Economic factors were declared in 6.5% of the trials. Only 2% of the trials attempted to measure the effect of an intervention on the quality of life patients.

CONCLUSIONS

Readers should be cautious when interpreting the results of surgical trials.

Quantification and localization of N-acetyl-beta-D-hexosaminidase in the adult rat testis and epididymis

An affinity-purified polyclonal antibody against N-acetyl-beta-D-hexosaminidase (EC 3.2.1.52) from adult rat epididymis was used to develop an ELISA, to localize tissue antigen by immunocytochemistry, and to identify isoforms of the enzyme by Western blot analysis. While peak activity level was measured in the corpus region of the epididymis, the quantity of soluble enzyme protein was highest in the caput region. Luminal caput sperm were intensely immunopositive, whereas epithelial cells were weakly stained. The enzyme was localized to epithelial and sperm cells of the corpus and caudal regions. In the testis, the enzyme was restricted primarily to lymphatic spaces. Testicular cells were unreactive, but spermatids were weakly stained. Western blot analysis revealed three prominent immune-reactive protein variants of approximately 63 kDa, approximately 55 kDa, and approximately 31 kDa. The approximately 31-kDa immune-reactive protein variant was reduced by > 84% in the caput epididymis compared to the cauda and corpus regions. These data suggest that regional differences in N-acetyl-beta-D-hexosaminidase activity in the rat epididymis may be due to differences in cellular synthesis and/or posttranslational processing of the enzyme.

A case-control study of postoperative pulmonary complications after laparoscopic and open cholecystectomy

Postoperative pulmonary complications (PPC) are common after upper abdominal surgery. The objective of this case-control study was to compare the incidence of PPC after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) within a tertiary care center. Patients were accrued from two sequential clinical trials that evaluated the role of incentive spirometry in the prevention of PPC after abdominal surgery. Included for study were patients with gallstones undergoing elective surgery who had an American Society of Anesthesiologists (ASA) classification < 3. All patients included in the study were encouraged to use an incentive spirometer at least 10 times each hour while awake. Patients with chronic bronchitis were excluded from study, as were patients who received other forms of physical therapy. OC was performed through either a transverse or an oblique incision. There was an equitable dispersion of putative risk factors for PPC between the groups at baseline. PPC were defined as clinical features consistent with collapse/consolidation, an otherwise unexplained temperature above 38 degrees C, plus either confirmatory chest radiology or positive sputum microbiology. The incidence of PPC was 2.7% (1/37) after LC and 17.2% (10/58) after OC (p < 0.05). It is concluded that PPC are less common after laparoscopic cholecystectomy than after open cholecystectomy.

Novel features of drosophila period Transcription revealed by real-time luciferase reporting

The rapid turnover of luciferase and the sensitive, non-invasive nature of its assay make this reporter gene uniquely situated for temporal gene expression studies. To determine the in vivo regulatory pattern of the Drosophila clock gene period (per), we generated transgenic strains carrying a luciferase cDNA fused to the promoter region of the per gene. This has allowed us to monitor circadian rhythms of bioluminescence from pacemaker cells within the head for several days in individual living adults. These high time-resolution experiments permitted neuronal per transcription and opens the door to vastly simplified experiments in general chronobiology and studies of temporally regulated transcription in a wide range of experimental systems.

Glutamine

Glutamine is the most abundant free amino acid in the circulation. It is a primary fuel for rapidly dividing cells and plays a key role in the transport of nitrogen between organs. Although glutamine is absent from conventional regimens aimed at nutritional support, glutamine deficiency can occur during periods of metabolic stress; this has led to the reclassification of glutamine as a conditionally essential amino acid. Experiments with various animal models have demonstrated that the provision of glutamine can result in better nitrogen homoeostasis, with conservation of skeletal muscle. There is also considerable evidence that glutamine can enhance the barrier function of the gut. This review concludes by discussing the clinical evidence that supports the inclusion of stable forms of glutamine in solutions of nutrients.

Defects in courtship and vision caused by amino acid substitutions in a putative RNA-binding protein encoded by the no-on-transient A (nonA) gene of Drosophila

The Drosophila no-on-transient A (nonA) gene is involved in the visual behaviors and courtship song of the fly. The NONA polypeptide contains two copies of the RNA-recognition motif (RRM), a hallmark of proteins involved in RNA binding, and an adjacent conserved charged region. This 311-amino-acid region is found in four other proteins and largely overlaps the Drosophila-Behavior/Human Splicing (or DBHS) domain. The newest family member, Drosophila nAhomo, was discovered in a database search, and encodes a protein with 80% identity to NONA. In this study, three nonA mutations generated by chemical mutagenesis were sequenced and found to fall within the conserved region. Site-directed mutagenesis of the two RRMs, and within a (conserved) charged region located C-terminal to them, was performed to determine the significance of these domains with respect to whole-organismal phenotypes. Behavior and viability were assessed in transformed flies, the genetic background of which lacks the nonA locus. Point mutations of amino acid 548 in the charged region confirmed the etiology of the nonAdiss courtship-song mutation and showed that a milder substitution at this site produced intermediate singing behavior, although it failed to rescue visual defects. Mutagenesis of the RRM1 domain resulted in effects on viability, vision, and courtship song. However, amino acid substitutions in RNP-II of RRM2 led to near-normal phenotypes, and the in vivo nonA mutations located in or near RRM2 caused visual defects only. Thus, we suggest that the first RRM could be important for all functions influenced by nonA, whereas the second RRM may be required primarily for normal vision.

Prevention of respiratory complications after abdominal surgery: a randomised clinical trial

OBJECTIVE

To evaluate the prevention of respiratory complications after abdominal surgery by a comparison of a global policy of incentive spirometry with a regimen consisting of deep breathing exercises for low risk patients and incentive spirometry plus physiotherapy for high risk patients.

DESIGN

Stratified randomised trial.

SETTING

General surgical service of an urban teaching hospital.

PATIENTS

456 patients undergoing abdominal surgery. Patients less than 60 years of age with an American Society of Anesthesia classification of 1 were considered to be at low risk.

OUTCOME MEASURES

Respiratory complications were defined as clinical features consistent with collapse or consolidation, a temperature above 38 degrees C, plus either confirmatory chest radiology or positive results on sputum microbiology. We also recorded the time that staff devoted to prophylactic respiratory therapy.

RESULTS

There was good baseline equivalence between the groups. The incidence of respiratory complications was 15% (35/231) for patients in the incentive spirometry group and 12% (28/225) for patients in the mixed therapy group (P = 0.40; 95% confidence interval -3.6% to 9.0%). It required similar amounts of staff time to provide incentive spirometry and deep breathing exercises for low risk patients. The inclusion of physiotherapy for high risk patients, however, resulted in the utilisation of an extra 30 minutes of staff time per patient.

CONCLUSIONS

When the use of resources is taken into account, the most efficient regimen of prophylaxis against respiratory complications after abdominal surgery is deep breathing exercises for low risk patients and incentive spirometry for high risk patients.

The effect of minimum luminal nutrition on bacterial translocation and atrophy of the jejunum during parenteral nutrition

In situations of catabolic stress, the gut becomes atrophic and may have diminished barrier function as evidenced by an increase in bacterial translocation. The aim of this study was to examine the effect of minimum luminal nutrition during parenteral nutrition on the extent of jejunal atrophy and rate of bacterial translocation. Central venous lines were inserted into 30 rats before they underwent randomization to receive nutritional support with: (a) conventional parenteral nutrition; (b) conventional parenteral nutrition with 3 g/day of rat food (i.e., minimum luminal nutrition); or (c) rat food ad libitum. The rats were assessed after 10 days for nutritional status, extent of jejunal atrophy, caecal flora, as well as the extent of bacterial translocation to the mesenteric lymph nodes, liver and spleen. Rats in the rat food ad libitum group lost the smallest amount of weight and had the least amount of jejunal atrophy, yet had a similar rate of bacterial translocation as the parenterally nourished groups. When compared with the conventional parenteral nutrition group, the minimum luminal nutrition group had better preservation of the weight of the small bowel and its isolated mucosa (P < 0.01), but had a similar rate of bacterial translocation. Minimum luminal nutrition reduced the extent of atrophy of the gut but did not affect the incidence of bacterial translocation. It is inferred that there is no direct relationship between the extent of mucosal atrophy and incidence of bacterial translocation.

Green fluorescent protein and its derivatives as versatile markers for gene expression in living Drosophila melanogaster, plant and mammalian cells

We have investigated the utility of the green fluorescent protein (GFP) as a marker for gene expression in living adult Drosophila melanogaster (Dm) and cultured plant and mammalian cells. Using Dm, we generated transgenic flies bearing a glass-responsive gfp fusion gene to test the utility of GFP as a spatial reporter. In the adult living fly, GFP is clearly visible in the ocelli and the eye. We have optimized the use of filters for distinguishing the GFP signal from abundant autofluorescence in living Dm. In addition, we have used GFP to identify photoreceptor cells in pupal eye cultures that have been fixed and stained according to standard histological procedures. GFP was also detected in individual living plant cells following transient transfection of soybean suspension cultures, demonstrating that GFP is an effective transformation marker in plant cells. Similarly, transient transfection of mammalian cells with a modified form of GFP, S65T, allowed detection of single living cells expressing the reporter. This modified form of GFP gave a robust signal that was resistant to photobleaching. We then used a CellScan system exhaustive photon reassignment (EPR) deconvolution algorithm to generate high-resolution three-dimensional images of GFP fluorescence in the living cell.

Continuous quality improvement in a day ward

The increasing usage of short-stay facilities within Australia has focused attention upon the efficiency of surgical day wards. Although the Australian Council on Healthcare Standards (ACHS) is actively promoting the development of clinical indicators for same-day facilities, there is a concern that these measurements relate to efficiency rather than to humanitarian aspects of the quality of service. We have established a programme of continuous quality improvement (CQI) in a surgical day ward with the nursing and clerical staff being empowered as core members of the team. Reviews and audits have identified a number of targets for our activity. Some issues have been resolved very easily (ward clerks telephoning patients to confirm admissions the next day) but the solution to some other problems has required lengthy negotiations between various groups (the construction of clearly written pre-admission guidelines for patients). Activities aimed at improving the service provided to patients attending surgical day wards must extend beyond the mere collection of information about clinical indicators.

Comparison of flash-induced light-scattering transients and proton efflux from auxinic-herbicide resistant and susceptible wild mustard protoplasts: a possible role for calcium in mediating auxinic herbicide resistance

Comparison of flash-induced light-scattering signals from protoplasts of auxinic herbicide-resistant ('R') and -susceptible ('S') wild mustard biotypes suggest that ATP-dependent activity manifested as a conformational change differs between the biotypes. The signal obtained from R protoplasts is unaffected by 50 microM picloram, an auxin analogue. In comparison, the signal amplitude from the S protoplasts decreases 40% in 20 microM picloram and is abolished in 50 microM picloram. Signal amplitude from the R protoplasts can be decreased by simultaneous incubation with 50 microM picloram and 50 microM verapamil, a calcium channel blocker. Incubation of the S protoplasts with the calcium ionophore A23187 in the presence of 0.5 mM calcium reduced the inhibitory effect of picloram. Absorbance spectrophotometry using acridine orange as a pH indicator suggests that picloram affects the proton flux in the S biotype only. Based on these results, we hypothesize that picloram affects the calcium and hydrogen dynamics in the S biotype. Because the scattering characteristics of S protoplasts incubated with picloram can be nearly reproduced in the R protoplasts by simultaneous incubation with picloram and verapamil, calcium may have a significant role in modulating auxinic herbicide resistance. To our knowledge, this is the first report to implicate such a role for calcium.

Tripping along the trail to the molecular mechanisms of biological clocks

Solving the mechanism of circadian clocks has become an important goal, in part because daily rhythms are running in such a wide variety of organisms, and contribute to many aspects of their well being. Systematic genetic approaches to studying 'the clock' were initiated in fruitflies more than 20 years ago as a novel means by which neural-pacemaking mysteries might be solved. Such chronogenetic investigations gained momentum when they spread to other species, and became molecular. However, the molecular studies were misleading, that is, until some elementary neuro-anatomical observations, involving the expression of a 'clock gene' in Drosophila, gave the experiments in this molecular-neurogenetic area of chronobiology a new direction. The initially neuro-descriptive studies led to the current investigations that involve negatively acting transcription factors and other clock molecules that are presumed to interact with them. In addition, new mutants and clones have been isolated in a timely manner. These mutations and molecules should permit chronogeneticists, working on a wide variety of organisms, to unravel further details of how the clock works, how environmental information finds its way to it, and how it sends information out into the organism's physiology, biochemistry and behavior.

Analysis of conditioned courtship in dusky-Andante rhythm mutants of Drosophila

Genetic connections between learning and rhythmicity were suggested to have been established in a previous study, in part because the duskyAndante (dyAnd) mutation in Drosophila disrupted both behaviors. dyAnd, isolated as a slow-clock variant, was reported to cause an approximately fourfold decrement in courtship-suppression conditioning. These effects have been reexamined; the experiments were buttressed by testing the effects of several recently isolated mutations at the dusky locus, along with the original And Allele that had been induced there. The reexamination was also prompted by anatomical concerns, certain of which have recently focused on dy-induced decrements in cell size, but only in terms of wing morphology. Another anatomical issue involves the discovery of a neuronal pathway that seems to connect circadian pacemaker cells to a structure in the Drosophila brain that is involved in learning. In observer-blind experiments, however, it was found that neither pacemaker-slowing (Andante-like) dy mutations nor others that cause no rhythm defects produced subnormal conditioned courtship. Moreover, in the adult brain of a slow-clock dyAnd mutant, no axonal pathway defects were readily discernible and putative pacemaker neurons appeared to be normal in size.

Acetylcholinesterase staining in the auditory brainstem nuclei of the leopard frog, Rana pipiens

We examined the distribution of acetycholinesterase (AChE) in the brainstem auditory nuclei of leopard frogs (Rana pipiens). Numerous AChE-labeled somata were observed in caudal brainstem nuclei including the dorsolateral nucleus, superior olivary nucleus, and superficial reticular nucleus. At midbrain levels, AChE-labeled somata were observed in the magnocellular, principal and laminar nuclei of the torus semicircularis, though, most were located in the magnocellular nucleus. Neuropil labeling, while present throughout the auditory brainstem, was particularly pronounced in the principal nucleus of the torus. These findings suggest that the auditory system of anurans, like that of birds and mammals, comprises, in part, distinct cholinergic pathways.

An ultrashort clock mutation at the period locus of Drosophila melanogaster that reveals some new features of the fly's circadian system

A rhythm mutant of Drosophila melanogaster was induced by chemical mutagenesis and isolated by testing for locomotor activity rhythms, which in the new variant had periods of approximately 16 hr. The sex-linked mutation responsible for this ultrashort period causes 20-hr rhythms when heterozygous with a normal X. This semidominance notwithstanding, the new mutation was revealed to be an allele of the period (per) gene by noncomplementation with per-null variants, in the sense that females heterozygous for perT (as the ultrafast-clock allele is called) and per- exhibited periods that were much shorter than in the case of perT/+. These tests also revealed in a clearer manner than in previous cases that two "doses" of a fast-clock per mutation lead to appreciably shorter periods than those exhibited by one-dose females whose other per allele is a loss-of-function variant. In light-dark cycles (LD 12:12), flies carrying perT in a genotypic condition leading to free-running periods that are 8 hr faster than normal nevertheless entrained, by phase-shifting that large number of hours each day; the evening peak of locomotor activity was, however, many hours earlier than normal. The use of a newly developed device for monitoring Drosophila eclosion automatically showed that perT exhibits a very marginal emergence rhythm at 25 degrees C, but periodicity of ca. 17-18 hr at 19 degrees. Staining of the per-encoded protein (PER) in sections of perT versus normal pharate adults revealed for the first time that the immunohistochemically detected signal cycles in its intensity in wild-type, in a manner that is similar to the PER rhythm previously demonstrated in adults. The staining cycle in pharate adults expressing perT differed from that of wild-type. Temperature compensation of the adult activity rhythm of perT was found to be faulty, in that periods became appreciably shorter as the flies were heated. However, the mutant exhibited a normal degree of period lengthening when its locomotor activity was monitored in the presence of heavy water. The perT mutation interacted with the long-period Andante allele of the dusky locus in a manner that was anomalous (in comparison to dyAnd interactions with per+ or another short-period per mutation). This and other unique features of perT are discussed from the standpoint of the new mutation's heuristic value, including that which may stimulate a deeper understanding of the period gene's action at the molecular level.

Dosage compensation of the period gene in Drosophila melanogaster

The period (per) gene is located on the X chromosome of Drosophila melanogaster. Its expression influences biological clocks in this fruit fly, including the one that subserves circadian rhythms of locomotor activity. Like most X-linked genes in Drosophila, per is under the regulatory control of gene dosage compensation. In this study, we assessed the activity of altered or augmented per+ DNA fragments in transformants. Relative expression levels in male and female adults were inferred from periodicities associated with locomotor behavioral rhythms, and by histochemically assessing beta-galactosidase levels in transgenics carrying different kinds of per-lacZ fusion genes. The results suggest that per contains multipartite regulatory information for dosage compensation within the large first intron and also within the 3' half of this genetic locus.

Educational interventions and the use of parenteral nutrition

The Georgetown Total Parenteral Nutrition Forum generated consensus statements about the need for nutrition support. The main concern is that the excessive use of parenteral nutritional is both dangerous and expensive. We performed confidential audits using these criteria before and after educational interventions. The incidence of doubtful usage decreased from 29% (8/28) in mid-1991 to 3% (1/30) in mid-1992 (Fisher Exact Probability = 0.01): A post-audit review one year later in mid-1993 revealed an incidence of doubtful usage of 0% (0/19). It is concluded that the consensus document from the Georgetown Parenteral Nutrition Forum is a useful tool for deriving usage guidelines, educating staff and performing criterion audits. In this way, it is possible to generate cost savings and improve the quality of care.

Australian National Diagnosis Related Groups and Abdominal surgery

This study compares the declared splits for abdominal surgery within the Australian National Diagnosis Related Groups (AN-DRG) with age-based strata. Data were derived from two clinical trials involving 2114 adults. The patients tended to be elderly (25% > 71 years) and had significant co-morbidity, that is, 57% with an American Society of Anesthesia (ASA) classification > 1. Adverse events after surgery included pulmonary complications (16%), urinary tract infections (10%), wound infection (6%), and death (4.5%). Only 27% of the patients could be classified into a 'non-complicated' AN-DRG partition; these patients had a median age of 25 years and 88% had either appendicectomy or cholecystectomy. In contrast, analysis of six age-based strata revealed a stepwise increase in the incidence of adverse events after surgery (Friedman ANOVA, P < 0.001). It might therefore be wise to consider the inclusion of age-strata in the abdominal surgery component of the AN-DRG. Failure to do so may result in financial penalties for hospitals that care for patients at high risk of an adverse outcome after abdominal surgery.

The mating of a fly

Courtship in Drosophila is influenced by a wide variety of genes, in that many different kinds of pleiotropic mutations lead to defective courtship. This may seem to be a truism, but the broad temporal and spatial expression of most of the fly's "neuro genes" makes it difficult to exclude elements of such genes' actions as materially underlying reproductive behavior. "Courtship genes" that seem to play more particular roles were originally identified as sensory, learning, or rhythm mutations; their reproductive abnormalities have been especially informative for revealing components of male or female actions that might otherwise have gone unnoticed. Further behavioral mutations seemed originally to be courtship-specific, turned out not to have that property, and have led to a broadened perspective on the nature and action of Drosophila's sex-determination genes.

Signet-ring cell variant of invasive lobular carcinoma of the breast. A clinicopathologic study of 11 cases

In signet-ring cell carcinoma of the breast, which was recognized in 1976 as a distinct clinicopathologic variant of lobular carcinoma, more than 20% of the malignant cells appear as signet rings formed by mucin-positive intracytoplasmic vacuoles. Several recent studies have demonstrated that the neoplasm behaves aggressively and is associated with a poor prognosis. However, the literature lacks information concerning steroid hormone receptor assays and DNA ploidy profiles, especially regarding how these tests affect a patient's prognosis. During a 5-year period (1985 to 1990), 11 (8.7%) of 126 cases of invasive lobular carcinoma met the criteria for signet-ring cell carcinoma. Ten of 11 cases were positive for estrogen and progesterone receptors; six cases showed type I and five showed type III DNA histograms. The high incidence of positive hormone receptors is significant: patients with receptor positive tumors, even those with type III DNA histograms, who were treated with tamoxifen citrate therapy after surgery had a significant increase in disease-free survival (30 months). Both the pathologist and the clinician should be aware of the prognostic influence of hormone receptor studies in the management of signet-ring cell carcinoma of the breast.

Spindle cell hemangioendothelioma. Report of three cases and review of the literature

BACKGROUND

Spindle cell hemangioendothelioma lesions are uncommon, affect a wide age range in both sexes, and show a predilection for skin and subcutaneous tissue of the extremities.

OBJECTIVE

To present three cases of spindle cell hemangioendothelioma and review the literature.

METHODS

Three cases of spindle cell hemangioendothelioma are presented.

RESULTS

Two of our cases first presented very early in life and progressed by local recurrences over many years. None of our cases showed evidence of metastases, but the lesions exhibited local aggressive and invasive behavior. Histologically, the lesions consist of alternating areas of dilated, thin walled cavernous vascular spaces and solid areas composed predominantly of spindle cells and clusters of epithelioid endothelial cells with intracytoplasmic vacuoles. That spindle cell hemangioendothelioma is a non-neoplastic lesion and not a neoplasm of borderline malignancy is suggested by the following observations from our cases: the repeated presence of organized intravascular thrombi in all cases, the early clinical presentation in two cases, and the presence of some degree of vascular malformation at the periphery of lesions.

CONCLUSION

Both clinicians and pathologists should be aware of the existence of this lesion in order to diagnose and treat an affected patient correctly.

A promoterless period gene mediates behavioral rhythmicity and cyclical per expression in a restricted subset of the Drosophila nervous system

Transgenic flies carrying a 7.2 kb piece of DNA from the period (per) gene were analyzed for the presence of circadian locomotor activity rhythms and fluctuations of per-encoded mRNA and protein. The 5' end of this genomic fragment is within the first intron, which precedes the coding region. This promotorless fragment could rescue circadian behavioral rhythms and mediate spatial expression of PER in a subset of wild-type per cells within the CNS and PNS. In one behaviorally rhythmic line, PER protein was found in only "per lateral neurons." In the rhythmic transgenics, per mRNA and protein levels undergo circadian cycling, as previously described for wild type. Cycling of PER in brain cells of flies carrying the same 7.2 kb piece of per DNA under the control of a heat shock promoter corroborated the hypothesis that per's molecular cyclings and behavioral rhythmicity are causally related.

Behavioral and neurobiological implications of sex-determining factors in Drosophila

The function of the central nervous system as it controls sex-specific behaviors in Drosophila has been studied with renewed intensity, in the context of genetic factors that influence the development of sexually differentiated aspects of this insect. Three categories of genetic variations that cause anomalies in courtship and mating behaviors are discussed: (1) mutants isolated with regard to courtship defects, of which putatively courtship-specific variants such as the fruitless mutant are a subset; (2) general behavioral and neurological variants (including sensory and learning mutants), whose defects include subnormal reproductive performance; and (3) mutations of genes within the sex-determination regulatory hierarchy of Drosophila, the analysis of which has included studies of reproductive behavior. Recent studies of mutations in two of these categories have provided new insights into the control of neuronally based aspects of sex-specific behavior. The doublesex gene, the final factor acting in the sex-determination hierarchy, had been previously thought to regulate all aspects of sexual differentiation. Yet, it has been recently shown that doublesex does not control at least one neuronally-determined feature of sex-specific anatomy--a muscle in the male's abdomen, whose normal development is, however, dependent on the action of fruitless. These considerations prompted us to examine further (and in some cases re-examine) the influences exerted by sex-determination hierarchy genes on behavior. Our results--notably those obtained from assessments of doublesex mutations' effects on general reproductive actions and on a particular component of the courtship sequence (male "singing" behavior)--lead to the suggestion that there is a previously unrecognized branch within the sex-determination hierarchy, which controls the differentiation of the male- and female- specific phenotypes of Drosophila. This new branch separates from the doublesex-related one immediately before the action of that gene (just after transformer and transformer-2) and appears to control as least some aspects of neuronally determined sexual differentiation of males.

Transfer of dye among salivary gland cells is not affected by genetic variations of the period clock gene in Drosophila melanogaster

Larval salivary gland cells of Drosophila melanogaster were injected with a fluorescent dye to assess strengths of intercellular communication among such cells, as influenced by mutations at the period locus and by a per transgene. This clock gene had been reported to increase the extent of dye transfer when mutated such that it shortens the period of biological rhythms; the previous study also showed that a per-null mutant decreased the strength of transfer among salivary gland cells. Our re-examination of this feature of larval physiology--in observer-blind analyses, using the pers and per0 mutants as well as two per-normal strains--revealed no appreciable differences in extents of dye transfer among these four genotypes. These results are discussed in the context of emerging findings which suggest that the period gene's product controls pacemaker functioning as an intracellularly acting entity.

Enzyme immunoassay based survey of precipitation and surface water for the presence of atrazine, metolachlor and 2,4-D

The suitability of enzyme immunoassay (EIA) as a method of analysis for 2,4-D, atrazine and metolachlor contamination in water samples was determined by comparing EIA results to gas chromatography (GC) results. The comparison of EIA and GC results yielded a correlation coefficient of 0.92, 0.98 and 0.92 for 2,4-D, atrazine and metolachlor, respectively. EIA was used to monitor seasonal trends in the concentrations of 2,4-D, atrazine and metolachlor in surface water and precipitation throughout the province of Ontario, Canada. 2,4-D was detected in excess of 4 micrograms/L in urban creeks during the period of application. Concentrations of 43 and 9 micrograms/L of atrazine and metolachlor, respectively, were detected during the field application period in surface water samples from the Kintore Creek watershed. The levels of 2,4-D, atrazine and metolachlor detected exceeded the Canadian Water Quality Guidelines for the protection of fresh water aquatic life. Concentrations as high as 445 and 322 ng/L of atrazine and metolachlor, respectively, were detected in precipitation samples collected from 17 locations in Ontario during the herbicide application period. The EIA was shown to be qualitatively and quantitatively comparable to GC analysis.

Antibiotic prophylaxis in cardiac operations

This clinical trial, which was composed of 1,031 adults undergoing cardiac operations, compared the efficacy of a single dose of 1 g of ceftriaxone with a 48-our regimen consisting of flucloxacillin and gentamicin. There was no significant difference (p = 0.89) in the overall incidence of major infections: 30 of 515 patients (5.8%; 95% confidence interval, 5.4% to 6.2%) taking ceftriaxone and 29 of 516 patients (5.6%; 95% confidence interval, 5.2% to 6.0%) taking flucloxacillin and gentamicin. Subgroup analyses, with a lower statistical power, failed to show a significant difference between patients who received ceftriaxone and those who received flucloxacillin/gentamicin: major sternal wound infections arose in 2.7% of the patients taking ceftriaxone versus 1.6% in those on the 48-hour regimen (p = 0.20) and major limb wound infections arose in 4.2% and 5.4%, respectively (p = 0.44). Single-dose prophylaxis was associated with fewer intravenous administrations (864 doses versus 9,570 doses) and cost less (A$17,248 versus A$78,510). Although the regimen that included gentamicin was associated with the greatest biochemical impairment of renal function, the overall toxicity for both groups was low. We conclude that a single dose of ceftriaxone provided cost-efficient prophylaxis for adults undergoing cardiac operations when compared with a 48-hour regimen of gentamicin and flucloxacillin. The general principle revealed by our data is that the short-term administration of an appropriate antibiotic regimen represents optimal prophylaxis for patients undergoing cardiac procedures.

The influence of age on endocrine responses to ultraendurance stress

BACKGROUND

Aging produces significant changes in the human endocrine system. This study was designed to determine if elderly and younger individuals differ in various endocrine measures before and after ultraendurance stress.

METHODS

Sixteen young and 19 older subjects competing in a world championship triathlon had blood samples acquired for 13 hormones before, immediately after the event, and 18 hours into recovery.

RESULTS

Following the triathlon, almost every hormone level increased. Significantly higher basal circulating levels of dihydroepiandrosterone sulfate (DHEA-S) and thyroid stimulating hormone (TSH) were found in 20-year-old individuals, whereas higher levels of norepinephrine (NEPI) and sex hormone binding globulin (SHBG) were found in the 50- to 74-year-old group. Older subjects had lower postexercise levels of EPI, DHEA-S, GH, and PRL and higher postexercise levels of estradiol than younger individuals. Similarity in pre- and postrace weights as well as Hgb and Hct levels suggested that dehydration, while present, did not significantly contribute to the endocrine changes.

CONCLUSIONS

Ultraendurance stress produced dramatic increases in all but one of the hormones evaluated. Whether frequent exercise can alter the endocrine changes that occur with aging cannot be answered by this study. It is clear, however, that when comparisons are made with young active individuals, frequent exercise does not eliminate the differences in basal concentrations of TSH, DHEA-S, SHBG, and NEPI or exercise-induced release of estradiol, GH, and PRL that occur with aging.

The cost-efficiency of incentive spirometry after abdominal surgery

This report gives the results of a cost-efficiency analysis of a prospective longitudinal study evaluating two forms of prophylaxis against postoperative pulmonary complications in 876 patients undergoing abdominal surgery. It cost $12.19 per patient for conventional chest physiotherapy, and equivalent costs accrue when incentive spirometers are recycled and used on average 2.3 times (in the Royal Perth Hospital, incentive spirometers are recycled an average of 4.7 times). Maximum cost-containment can be achieved by carefully selecting patients for physical chest care and then instigating a programme of perioperative chest care utilizing recycled incentive spirometers. This approach does not compromise the clinical benefits of prophylactic chest care and allows physiotherapy resources to be directed toward patients with established pulmonary problems.

Behavior in light-dark cycles of Drosophila mutants that are arrhythmic, blind, or both

Certain of the rhythm mutations in Drosophila melanogaster lead to arrhythmic locomotor activity (and aperiodic eclosion) in constant conditions. In light-dark (LD) cycles, however, such mutants exhibit clear fluctuations between high levels of activity when the lights are on and much lower ones when they are off. Our data, in contrast to some previous conclusions, strongly suggest that period0 (per0) adults are, in LD conditions, merely being "forced" into exhibiting periodic behavior. These experiments involved application of 8-, 12-, 16-, and 24-hr LD cycles, in which the arrhythmic mutant could have any of these periodicities imposed upon it, whereas wild-type flies tended to exhibit periods of about 24 hr in cycling conditions whose T values were > 8 hr different from 24. In phase-shift experiments, it was found that Drosophila expressing genotypes associated with rhythmicity achieved a 5-hr advance over a 2-day period following an advanced lights-on; per0 adults altered the phase of their locomotor peaks more rapidly. Against a background of the fact that eyeless or blind flies exhibit normal entrainment, it was hypothesized that double-mutant flies--carrying such visual mutations and per0 as well--should not synchronize to LD cycles, if the forced rhythms seen in the latter single-mutant type are mediated solely by light input through the external photoreceptors. Since an appreciable proportion of the double mutants did synchronize (to LD 12:12), it is thus suggested that the visual cues involved in forcing rhythmicity could be input through the same extraocular photoreceptors that, in general, subserve the fly's rhythm system.

Circadian oscillations in period gene mRNA levels are transcriptionally regulated

The period (per) gene is involved in regulating circadian rhythms in Drosophila melanogaster. The per gene is expressed in a circadian manner, where fluctuations in per mRNA abundance are influenced by its own translation product, which also cycles in abundance. Since per gene expression is necessary for circadian rhythmicity, we sought to determine how certain features of this feedback loop operate. The results of this study reveal that fluctuations in per mRNA are primarily controlled by fluctuations in per gene transcription, that per mRNA has a relatively short half-life, and that sequences sufficient to drive per mRNA cycling are present in 1.3 kilobases of 5' flanking sequences. These and other results indicate that the per feedback loop has all of the basic properties necessary to be a component of a circadian oscillator.

Purification and characterization of N-acetyl-beta-D-hexosaminidase in different anatomical regions of the adult rat epididymis

The purpose of the present study was to purify and kinetically characterize N-acetyl-beta-D-hexosaminidases A and B (EC 3.2.1.52) from the caput, corpus and caudal regions of the adult rat epididymis. The molecular mass of the purified native enzyme was approximately 250,000 and approximately 223,000 daltons for the A and B isozymes, with a subunit molecular mass of approximately 63,000 and approximately 56,000 daltons, as determined by size exclusion chromatography and gel electrophoresis under reducing conditions. The apparent Michaelis-Menten constant and maximum velocity values were 0.60, 1.55 and 0.68 mM and 0.54, 3.20 and 2.30 microM/min./mg protein for the enzyme purified from the caput, corpus and caudal regions, respectively. These values were determined by using p-nitrophenyl-N-acetyl-beta-D-glucosaminide as the substrate. These data suggest that the enzyme may be more active in the corpus region of the epididymis than in the caput and caudal regions.

Evolution of the threonine-glycine repeat region of the period gene in the melanogaster species subgroup of Drosophila

The Threonine-Glycine (Thr-Gly) region of the period gene (per) in Drosophila was compared in the eight species of the D. melanogaster subgroup. This region can be divided into a diverged variable-length segment which is flanked by more conserved sequences. The number of amino acids encoded in the variable-length region ranges from 40 in D. teissieri to 69 in D. mauritiana. This is similar to the range found within natural populations of D. melanogaster. It was possible to derive a Thr-Gly "allele" of one species from that of another by invoking hypothetical Thr-Gly intermediates. A phylogeny based on the more conserved flanking sequences was produced. The results highlighted some of the problems which are encountered when highly polymorphic genes are used to infer phylogenies of closely related species.

Expression of the period clock gene within different cell types in the brain of Drosophila adults and mosaic analysis of these cells' influence on circadian behavioral rhythms

The product of the period (per) gene of Drosophila melanogaster is continuously required for the functioning of the circadian pacemaker of locomotor activity. We have used internally marked mosaics to determine the anatomical locations at which per expression is required for adult rhythmicity, and thus where the fly's circadian pacemaker is likely located in this holometabolous insect. We first provide a detailed description of the distribution and nature of per-expressing cells in the fly's CNS. Using an antibody to the per gene product, or to that of a reporter of per expression, in conjunction with an antibody to the embryonic lethal-abnormal visual system (elav) gene product--which is used as a marker of neuronal identity--we have experimentally confirmed previously proposed assignments of per-expressing cells to the neuronal and glial classes. Thus, we found that per expression and elav immunoreactivity colocalized in large cells located in the lateral cortex of the central brain, as well as in more dorsally located cells in the posterior central brain. In contrast, we found that cells located at the margins of the cortex and the neuropil, and within the neuropil, as well as smaller cortical cells found throughout the brain's cortex, were elav negative, supporting the notion that they are glial in nature. Using internally marked mosaics, we find that the pacemaker is located in brain but is not exclusive to the eyes, the ocelli, or the optic lobes, which is consistent with previous reports obtained in this and other insects of this class. Although the pacemaker may be a paired structure, we show that the functioning of one of them is sufficient for rhythmicity. Finally, we report that glial expression is sufficient for some behavioral rhythmicity to be manifest. However, the rhythmicities of animals for which per expression was confined to glia were weak, suggesting that neuronal per expression as well may be required for normal pacemaker function.

Mapping the clock rhythm mutation to the period locus of Drosophila melanogaster by germline transformation

The Clock (Clk) mutation shortens circadian rhythms of locomotor activity and eclosion from ca. 24 h to 22.5-23 h. Clk was previously mapped, by meiotic recombination, very close to the period(per) locus on the X chromosome. To determine whether Clk is a mutation within the per gene or if the former is separate from the latter, two overlapping genomic fragments were cloned from Clk flies to produce a per-containing 13.2 kb construct, per01 flies (which by themselves are arrhythmic)--when transformed with this construct--expressed short-period rhythms. This indicates that the Clk mutation is contained within this 13.2 kb region and is almost certainly a new "fast-clock" allele of per.

Identification of novel RNA-binding proteins that interact in the coding region of protein D sense RNA in vitro

Ultraviolet (UV)-cross-linking and sodium dodecyl sulfate(SDS) polyacrylamide gel electrophoretic (PAGE) analysis were used to identify proteins of nuclear and cytosolic (S100) origin that specifically bind to an in vitro transcribed mRNA sequence for protein D. The coding region of the protein D cDNA was subcloned, in vitro transcribed to [32P]RNA, and incubated with nuclear and cytosolic extracts of enzymatically dispersed epididymal cells. As revealed by UV-cross-linking and SDS-PAGE analysis, two proteins exhibiting a molecular weight mass of approximately 2.5 and approximately 35 Kd that specifically recognize and bind to the in vitro transcribed mRNA sequence for protein D. Our findings suggest that the regulation of protein D gene expression in the rat epididymis may involve novel RNA-binding proteins.

The period gene encodes a predominantly nuclear protein in adult Drosophila

The period gene of Drosophila melanogaster (per) is important for the generation and maintenance of biological rhythms. Previous light microscopic observations indicated that per is expressed in a variety of tissues and cell types and suggested that the per protein (PER) may be present in different subcellular compartments. To understand how PER influences circadian rhythms, it is important to define its subcellular location, especially in adult flies where inducible promoter experiments suggested that it is most relevant to circadian locomotor activity rhythms. To this end, we report the results of an immunoelectron microscopic analysis of wild-type flies and per-beta-galactosidase (beta-gal) fusion gene transgenics using a polyclonal anti-PER antibody or an anti-beta-gal antibody, respectively. Most of the PER antigen and the fusion gene product were located within nuclei, suggesting that PER acts in that subcellular compartment to affect circadian rhythms. The results are discussed in terms of per's possible biochemical functions.

Selective embolisation of intrahepatic aneurysms

The radiological techniques that can be used to selectively embolise small arteries have improved markedly in the past few years. This article discusses the use of transcatheter embolisation in the management of three patients with aneurysms involving the intrahepatic arterial tree.