310 MARKER-GENE EXCISION IN TRANSGENIC CLONED SOMATIC CELLS AND EFFECTS ON RECLONED EMBRYO DEVELOPMENT IN CATTLE

Recently, it has become common to produce transgenic cattle by somatic cell nuclear transfer. As a major step, donor cells are transfected with expression vectors that contain not only the target gene but also marker genes such as neomycin resistant gene (neoR) used for subsequent cell screening. However, such markers in transgenic animals may be undesirable for further researches (Kuroiwa et al. 2004 Nature Genetics 36, 775–780). Therefore, the aim of this study was to excise the marker gene (neoR) in transgenic cattle by using transiently expressed CRE recombinase. Initially, the presence of loxP sites flanking neoR was confirmed in fibroblast cells derived from human lysozyme transgenic cloned cattle. By using cassettes from plasmids PBS185, pIRES-EGFP and pIREShyg3, IRES-EGFP element was inserted downstream of the CRE coding region, and the co-expression vector, which permits translation of GFP and CRE from one messenger RNA, was constructed. Then transgenic fibroblast cells were transfected by the CRE expression vector in circular format by Lipofectamine™ 2000 and screened by FACS after 48 h. GFP positive cells were selected to culture for 7 to 9 days, and removal of neoR was confirmed by PCR with 2000 to 3000 cells from each colony and the remaining cells used as donors for recloning. Then cleavage and blastocyst rate were evaluated; neoR excision was identified by single blastocyst PCR. Some blastocysts were harvested for differential staining and some used to conduct embryo transfer to evaluate in vitro and in vivo developmental ability. Data were analyzed using SAS (version 9.1) with one-way ANOVA. All experiments were replicated at least three times. We confirmed that loxP sites are correctly located at two sides of neoR. After transfection, neoR was removed from transgenic cloned fibroblast cells and cre was found to be expressed transiently. Additionally, neoR excision was confirmed by single blastocyst PCR. Furthermore, no significant difference was found on cleavage (P = 0.15) and blastocyst rate (P = 0.73) between cloned embryos when using neoR free donors and neoR included donors. The differential staining study showed similar numbers in terms of total cell number (P = 0.69) and the ratio of ICM to total cell number (P = 0.96). After embryo transfer, successful establishment of pregnancies were observed and pregnancy rate on Day 90 and Day 120 (Day 1 is the 1st day after embryo transfer) are similar with control (P > 0.05). In conclusion, we successfully excised resistant marker gene from transgenic cloned cattle by transient expression of CRE recombinase and we expect it will benefit bioreactor and animal transgenic research in the future.

A method to quantitatively measure the elastic modulus of materials in nanometer scale using atomic force microscopy

A method is proposed for quantitatively measuring the elastic modulus of materials using atomic force microscopy (AFM) nanoindentation. In this method, the cantilever deformation and the tip-sample interaction during the early loading portion are treated as two springs in series, and based on Sneddon's elastic contact solution, a new cantilever-tip property α is proposed which, together with the cantilever sensitivity A, can be measured from AFM tests on two reference materials with known elastic moduli. The measured α and A values specific to the tip and machine used can then be employed to accurately measure the elastic modulus of a third sample, assuming that the tip does not get significantly plastically deformed during the calibration procedure. AFM nanoindentation tests were performed on polypropylene (PP), fused quartz and acrylic samples to verify the validity of the proposed method. The cantilever-tip property and the cantilever sensitivity measured on PP and fused quartz were 0.514 GPa and 51.99 nm nA(-1), respectively. Using these measured quantities, the elastic modulus of acrylic was measured to be 3.24 GPa, which agrees well with the value measured using conventional depth-sensing indentation in a commercial nanoindenter.

Disruption of Spodoptera exigua larval development by silencing chitin synthase gene A with RNA interference

RNA interference (RNAi) is a powerful tool for rapidly analyzing gene functions. However, little is known about the possible use of dsRNA/siRNA as a pest control method. Here, we demonstrate that dsRNA/siRNA can induce the silence of chitin synthase gene A (CHSA), which is an important gene for the growth and development of cuticles and trachea in beet armyworm, Spodoptera exigua. Based on the in vitro RNAi experiments in an insect cell line (Trichoplusia ni High 5), in vivo RNAi was performed by injecting synthesized dsRNA/siRNA into the 4th instar larvae of S. exigua. Significantly lower levels of CHSA transcripts were detected. In addition, the cuticle of these insects was disordered and the epithelial walls of larval trachea did not expand uniformly in injected individuals. Moreover, Injections significantly increased abnormalities relative to control larvae. These results highlighted the possibility of dsRNA/siRNA for gene function studies in lepidopteran insects and future pest control.

Glycyrrhizin attenuates endotoxin- induced acute liver injury after partial hepatectomy in rats

Massive hepatectomy associated with infection induces liver dysfunction, or even multiple organ failure and death. Glycyrrhizin has been shown to exhibit anti-oxidant and anti-inflammatory activities. The aim of the present study was to investigate whether glycyrrhizin could attenuate endotoxin-induced acute liver injury after partial hepatectomy. Male Wistar rats (6 to 8 weeks old, weighing 200-250 g) were randomly assigned to three groups of 24 rats each: sham, saline and glycyrrhizin. Rats were injected intravenously with lipopolysaccharide (LPS) 24 h after 70% hepatectomy. Glycyrrhizin, pre-administered three times with 24 h intervals 48 h before hepatectomy, prolonged the survival of rats submitted to partial hepatectomy and LPS injection, compared with saline controls. Glycyrrhizin was shown to attenuate histological hepatic changes and significantly reduced serum levels of aspartate aminotransferase, alanine aminotransferase, and lactic dehydrogenase, at all the indicated times (6 rats from each were sacrificed 1, 3, 6, and 9 h after LPS injection), compared with saline controls. Glycyrrhizin also significantly inhibited hepatocyte apoptosis by down-regulating the expression of caspase-3 and inhibiting the release of cytochrome C from mitochondria into the cytoplasm. The anti-inflammatory activity of glycyrrhizin may rely on the inhibition of release of tumor necrosis factor-a, myeloperoxidase activity, and translocation of nuclear factor-kappa B into the nuclei. Glycyrrhizin also up-regulated the expression of proliferating cell nuclear antigen, implying that it might be able to promote regeneration of livers harmed by LPS. In summary, glycyrrhizin may represent a potent drug protecting the liver against endotoxin-induced injury, especially after massive hepatectomy.

Proficiency-gain curve for an advanced laparoscopic procedure defined by observation clinical human reliability assessment (OCHRA)

BACKGROUND

There is no established method for defining when a surgeon reaches the proficiency plateau in performing a specific operation. The published literature refers to "learning curves" based on retrospective evaluation of operative time, conversion rates, morbidity etc., which lack objectivity and do not address individual human factors. A more useful study of the gain in proficiency by the individual surgeon for a particular operation may be obtained using observational clinical-human reliability assessment (OCHRA).

METHODS

Following an 8-month fellowship in advanced laparoscopic surgery, the surgeon M.T. performed, independently at his own hospital, a prospective series of 20 palliative bypass operations for advanced gastric or pancreatic cancer. Unedited videotapes of gastro-jejunostomy (GJ) or cholecysto-jejunostomy (CJ) were analyzed independently in the training institution by the OCHRA technique.

RESULTS

For this surgeon proficiency in executing laparoscopic palliative bypass was reached after the 14th anastomosis when efficient execution (reduction in operative time) was accompanied by significant reduction in technical errors and improved economy of movement (reduction of the economy of movement index from 7-5 to 3-2). The majority of errors were enacted in component tasks associated with intracorporeal suturing. The declining incidence of these errors with experience was an integral component of the proficiency-gain curve. The important performance-shaping factors identified were: concentration lapses (n=1,321), misjudgments (n=209), poor camera work (n=193), fatigue (n=128), and impaired coordination (n=108).

CONCLUSIONS

This study has confirmed that OCHRA can describe quantitatively the proficiency-gain curve for a laparoscopic operation and indicate the plateau stage when the individual surgeon attains maximal performance in the execution of a specific procedure.

A preliminary microsatellite genetic map of the ostrich (Struthio camelus)

Molecular genetic maps can provide information for the identification and localization of major genes associated with quantitative traits. However, there are currently no published genetic linkage maps for any ratites. Herein, a preliminary genetic map of ostrich was developed using a two-generation ostrich reference family by linkage analysis of 104 polymorphic microsatellite markers, including 40 novel markers reported in this study. A total of 35 microsatellite markers were placed into 13 linkage groups. Five linkage groups are composed of three or more loci, whereas the remaining eight groups each contained two markers. The sex-averaged map spans 365.4 cM. The marker interval of each linkage group ranges from 5.3 to 25.4 cM, and the average interval distance is 16.61 cM. The male map covers 342.7 cM, with an average intermarker distance of 15.58 cM, whereas the female map is 456.7 cM, with the average intermarker spacing of 20.76 cM. In order to screen the orthologous loci between ostrich and chicken, all of the flanking sequences of the 104 polymorphic loci, nine monomorphic loci and a further 12 reported microsatellite loci for ostrich were screened against the chicken genomic sequence using the BLAST algorithm (Altschul et al., 1990), and corresponding orthologs were found for 13 sequences. The microsatellite loci and genetic map developed in this study will be useful for QTL mapping, population genetics and phylogenetic studies in the ratite. In addition, the 13 orthologous loci identified in this study will be advantageous to the construction of a comparative genetic map between chicken and ostrich.

The visceromotor response to colorectal distention fluctuates with the estrous cycle in rats

The existence of a sex difference in several chronic pain syndromes and the fluctuation of symptoms during the menstrual cycle strongly suggest sex hormones are involved in pain processing. The mechanisms underlying these changes are not well understood. Using the colorectal distention model in the rat, we previously reported a sex difference in the response to distention [Ji Y, Murphy AZ, Traub RJ (2006) Sex differences in morphine induced analgesia of visceral pain are supraspinally and peripherally mediated. Am J Physiol Regul Integr Comp Physiol 291:R307-R314] and that ovariectomy decreased the responses to distention while estrogen replacement reversed the decrease [Ji Y, Murphy AZ, Traub RJ (2003) Estrogen modulates the visceromotor reflex and responses of spinal dorsal horn neurons to colorectal stimulation in the rat. J Neurosci 23:3908-3915], suggesting estrogen increases visceral nociception. In the present study we tested the hypothesis that the visceromotor response to colorectal distention fluctuates with the estrous cycle. Three measurements (vaginal smears, uterine tube weight and plasma estrogen concentration) were used to determine the estrous phase. Comparison of the visceromotor response threshold and magnitude was made between proestrus and metestrus/diestrus. Our experiment demonstrated that the distention threshold was significantly lower in proestrus (median: 15 mm Hg) as compared with metestrus/diestrus (median: 25 mm Hg); and the magnitude of the visceromotor response to graded intensities of colorectal distentions (20, 40, 60, 80 mm Hg) was significantly higher in proestrus. The results indicate that the visceromotor response fluctuates with estrous phase, providing evidence for endogenous estrogen modulation of visceral nociceptive processing that could contribute to sex differences.

Non-linear optical properties of zinc oxide nanowires

High quality zinc oxide (ZnO) nanowires were grown on n-type Si (100) using vapor-liquid-solid process. We obtained the photoluminescence spectra of ZnO nanowires based on nonlinear optical process using an ultrashort wavelength femtosecond laser as a pumping source. The spectra shows the second harmonic generation phenomenon, as well as the exciton-exciton collision peak at 388 nm and the green emission peak at 515 nm caused by oxygen vacancy. A laser emission peak near 392 nm was observed when pump intensity surpassed 52 mJ/cm2 and a sharp peak about 0.5 nm wide emerged when the energy intensity reached 700 mJ/cm2. We attribute this excitation process to a two-photon absorption process enhanced by Rabi oscillation.

Effect of weight-bearing on bone-bonding behavior of strontium-containing hydroxyapatite bone cement

The purpose of this study was to investigate and compare the chemical composition and nanomechanical properties at the bone-cement interface under non-weight-bearing and weight-bearing conditions, in order to understand the effect of weight-bearing on the bone-bonding behavior of strontium-containing hydroxyapatite (Sr-HA) cement. In one group, Sr-HA cement was injected into rabbit ilium (under non-weight-bearing conditions). Unilateral hip replacement was performed with Sr-HA cement (under weight-bearing conditions) in the other group. Six months later, scanning electron microscopy (SEM) with energy-dispersive X-ray (EDX) analysis and nanoindentation tests were conducted on the interfaces between cancellous bone and the Sr-HA cement. The nanoindentation results revealed two different transitional behaviors under different conditions. nder weight-bearing conditions, both the Young modulus and hardness at the interface were considerably higher than those at either the Sr-HA cement or cancellous bone. On the contrary, under non-weight-bearing conditions, both the Young modulus and hardness values at the interface were lower than those at the cancellous bone, but were higher than the Sr-HA cement. In addition, EDX results showed that the calcium and phosphorus contents at the interface under weight-bearing conditions were considerably higher than those under non-weight-bearing conditions. The differences in chemical composition and nanomechanical properties at the cement-bone interface under two different conditions indicate that weight-bearing produces significant effects on the bone-bonding behavior of the Sr-HA cement.

Extent of innate dexterity and ambidexterity across handedness and gender: Implications for training in laparoscopic surgery

BACKGROUND

As innate dexterity is considered one of the important predictors of eventual operative competence, an experimental human factors study was conducted to determine innate dexterity and ambidexterity across handedness and gender.

METHODS

50 medical students (right-handed males, left-handed males, and right-handed females) were recruited as participants in a study designed to assess innate dexterity and degree of ambidexterity for endoscopic manipulations in a validated virtual-reality simulator. All participants performed unilateral and bilateral tasks with both dominant and nondominant hands in random sequence. The outcome measures were execution time, extent of ambidexterity (ambidexterity index), aiming errors, and maximum tissue damage.

RESULTS

Right-handed males exhibited a greater level of ambidexterity than left-handed males (p = 0.02 for path length, p = 0.001 for angular path) and right-handed females (p = 0.01 for path length, p = 0.02 for angular path), and more-efficient task performance as measured by execution time (p = 0.001 for males and p = 0.03 across gender). The task quality when executed by the dominant hand was best in right-handed males (p = 0.001 vs. left-dominant males and p = 0.03 across gender). No significant difference was observed in terms of precision control and fine movements (aiming errors and maximum tissue damage) between the three groups.

CONCLUSIONS

These findings indicate that training surgical curricula in laparoscopic surgery should be more flexible to accommodate the innate differences across handedness and gender.

An improved method for the measurement of mechanical properties of bone by nanoindentation

Nanoindentation is widely used to measure the mechanical properties of bio-tissues. However, viscoelastic effects during the nanoindentation are seldom considered rigorously, although they are in general very significant in bio-tissues. In this study, a recently developed method for correcting the viscoelastic effects during nanoindentation is applied to mice bone samples. This method is found to yield reliable elastic modulus and hardness results from forelimb and femur cortical bone samples of C57 BL/6N and ICR mice. The creep properties of the samples are also characterized by a novel procedure using nanoindentation. The measured mechanical properties correlate well with the calcium content of the bone samples.

Response surface methodology for optimizing the fermentation medium of alpha-galactosidase in solid-state fermentation

AIMS

Alpha-galactosidase is applied in food and feed industries for hydrolysing raffinose series oligosaccharides (RO) that are the factors primarily responsible for flatulence upon ingestion of soybean-derived products. The objective of the current work was to develop an optimal culture medium for the production of alpha-galactosidase in solid-state fermentation (SSF) by a mutant strain Aspergillus foetidus.

METHODS AND RESULTS

Response surface methodology (RSM) was applied to evaluate the effects of variables, namely the concentrations of wheat bran, soybean meal, KH(2)PO(4), MnSO(4).H(2)O and CuSO(4).5H(2)O on alpha-galactosidase production in the solid substrate. A fractional factorial design (FFD) was firstly used to isolate the main factors that affected the production of alpha-galactosidase and the central composite experimental design (CCD) was then adopted to derive a statistical model for optimizing the composition of the fermentation medium. The experimental results showed that the optimum fermentation medium for alpha-galactosidase production by Aspergillus foetidus ZU-G1 was composed of 8.2137 g wheat bran, 1.7843 g soybean meal, 0.001 g MnSO(4).H(2)O and 0.001 g CuSO(4).5H(2)O in 10 g dry matter fermentation medium.

CONCLUSIONS

After incubating 96 h in the optimum fermentation medium, alpha-galactosidase activity was predicted to be 2210.76 U g(-1) dry matter in 250 ml shake flask. In the present study, alpha-galactosidase activity reached 2207.19 U g(-1) dry matter.

SIGNIFICANCE AND IMPACT OF THE STUDY

Optimization of the solid substrate was a very important measure to increase enzyme activity and realize industrial production of alpha-galactosidase. The process of alpha-galactosidase production in laboratory scale may have the potential to scale-up.

The effects of interleukin-18 on rat articular chondrocytes: a study of mRNA expression and protein synthesis of proinflammatory substances

Interleukin (IL)-18 is a potent stimulator of immunity and augments the severity of type II collagen-induced arthritis (CIA) in rats and mice by enhancing T helper 1 (Th1) cell activation, which increases the production of proinflammatory cytokines and arthritogenic antibodies. In this study, we show that recombinant IL-18 (rIL-18) also has a direct effect on normal rat chondrocytes maintained in vitro inducing them to produce proinflammatory factors including IL-6, regulated upon activation normal T cell expressed and secreted (RANTES), prostaglandin E(2) (PGE(2)) and prostaglandin F(2alpha) (PGF(2alpha)) in a dose- and time-dependent manner. The production of matrix metalloproteinase (MMP)-13, nitric oxide (NO), tumour necrosis factor (TNF)-alpha and IL-1beta were also enhanced, although less intensely. Neutralizing polyclonal anti-rIL-18 antibodies effectively blocked the production of IL-6, PGE(2) and RANTES, as well as mRNA expression for the same products in addition to IL-18 and TNF-alpha. In contrast, neutralizing antibodies to IL-1beta, TNF-alpha and IL-6 were ineffective in suppressing any of these products. Together, these findings suggest that IL-18 may play an important, possibly direct, role in mediating cartilage injury, which might not be amenable to treatment with currently utilized anti-cytokine agents. These findings suggest further that IL-18 antagonists might prove beneficial as anti-inflammatory and chondroprotective agents in the treatment of arthritis, and that the development of such agents for human use is worth consideration.

Competence Assessment of Laparoscopic Operative and Cognitive Skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA)

BACKGROUND

There is no agreed system that is acknowledged as the ideal assessment of laparoscopic operative and cognitive skills. A new approach that combines Objective Structured Clinical Examination (OSCE) and Observational Clinical Human Reliability Assessment (OCHRA) was developed and used to assess trainees' operative and cognitive skills during laparoscopic training courses.

METHODS

Performance of 60 trainees participating in 3-day essential laparoscopic skills training (cognitive and psychomotor) courses were assessed and scored using both OSCE and OCHRA.

RESULTS

The study showed significant inverse correlations between the number of technical errors identified by OCHRA and the scores obtained by OSCE for individual tasks performed either by electro-surgical hook or laparoscopic scissors (r = -0.864 and r = -0.808, respectively). Significant differences between trainees were observed in relation to both overall OSCE scores and OCHRA parameters: execution time, total errors, and consequential errors (P < 0.001).

CONCLUSIONS

OCHRA provides a discriminative feedback assessment of laparoscopic operative skills. OCHRA and OSCE are best regarded as complementary assessment tools for operative and cognitive skills. The present study has documented significant variance between surgical trainees in the acquisition of both cognitive and operative skills.

Nano-mechanics of bone and bioactive bone cement interfaces in a load-bearing model

Many bioactive bone cements were developed for total hip replacement and found to bond with bone directly. However, the mechanical properties at the bone/bone cement interface under load bearing are not fully understood. In this study, a bioactive bone cement, which consists of strontium-containing hydroxyapatite (Sr-HA) powder and bisphenol-alpha-glycidyl dimethacrylate (Bis-GMA)-based resin, was evaluated in rabbit hip replacement for 6 months, and the mechanical properties of interfaces of cancellous bone/Sr-HA cement and cortical bone/Sr-HA cement were investigated by nanoindentation. The results showed that Young's modulus (17.6+/-4.2 GPa) and hardness (987.6+/-329.2 MPa) at interface between cancellous bone and Sr-HA cement were significantly higher than those at the cancellous bone (12.7+/-1.7 GPa; 632.7+/-108.4 MPa) and Sr-HA cement (5.2+/-0.5 GPa; 265.5+/-39.2 MPa); whereas Young's modulus (6.3+/-2.8 GPa) and hardness (417.4+/-164.5 MPa) at interface between cortical bone and Sr-HA cement were significantly lower than those at cortical bone (12.9+/-2.2 GPa; 887.9+/-162.0 MPa), but significantly higher than Sr-HA cement (3.6+/-0.3 GPa; 239.1+/-30.4 MPa). The results of the mechanical properties of the interfaces were supported by the histological observation and chemical composition. Osseointegration of Sr-HA cement with cancellous bone was observed. An apatite layer with high content of calcium and phosphorus was found between cancellous bone and Sr-HA cement. However, no such apatite layer was observed at the interface between cortical bone and Sr-HA cement. And the contents of calcium and phosphorus of the interface were lower than those of cortical bone. The mechanical properties indicated that these two interfaces were diffused interfaces, and cancellous bone or cortical bone was grown into Sr-HA cement 6 months after the implantation.

Genotype-phenotype correlation in Costello syndrome: HRAS mutation analysis in 43 cases

BACKGROUND

Costello syndrome (CS) is a rare multiple congenital abnormality syndrome, associated with failure to thrive and developmental delay. One of the more distinctive features in childhood is the development of facial warts, often nasolabial and in other moist body surfaces. Individuals with CS have an increased risk of malignancy, suggested to be about 17%. Recently, mutations in the HRAS gene on chromosome 11p13.3 have been found to cause CS.

METHODS

We report here the results of HRAS analysis in 43 individuals with a clinical diagnosis of CS.

RESULTS

Mutations were found in 37 (86%) of patients. Analysis of parental DNA samples was possible in 16 cases for both parents and in three cases for one parent, and confirmed the mutations as de novo in all of these cases. Three novel mutations (G12C, G12E, and K117R) were found in five cases.

CONCLUSIONS

These results confirm that CS is caused, in most cases, by heterozygous missense mutations in the proto-oncogene HRAS. Analysis of the major phenotypic features by mutation suggests a potential correlation between malignancy risk and genotype, which is highest for patients with an uncommon (G12A) substitution. These results confirm that mutation testing for HRAS is a reliable diagnostic test for CS.

Minimal access surgery (MAS)-related surgeon morbidity syndromes

The benefits of minimal access surgery (MAS) in terms of accelerated recovery, reduced period of short-term disability, and patient outcome account for the widespread use of the laparoscopic approach by the majority of general surgeons. In adopting this approach with its current limitations and poor ergonomics, surgeons have been known to sustain surgery-related injuries encompassed by a spectrum best described as MAS-related surgeon morbidity syndromes, some of which are currently overlooked and poorly researched. Equivalent morbidities including the overuse syndrome (from overuse of certain muscle groups during long operations) have been documented in open surgery but are nowadays rare occurrences. As more advanced MAS operations are performed with long execution times, new patterns of neuromusculoskeletal injuries are being recognized. The surgical fatigue syndrome has also been described, though its complex nature is not fully understood. Virtually little is known on other long-term adverse effects on the surgeon following many years of operating from images displayed on a television monitor or LCD screen, and these include deterioration of visual acuity and function of the ocular muscles responsible for fixation-refixation of the eyeballs. The limited reported literature on the MAS-related surgeon morbidity syndromes identifies certain risk factors for these injuries pertaining to central and peripheral domains. Only improved knowledge of the etiology and underlying ergonomic factors based on investigative studies followed by improved instrumentation and operating room (OR) ergonomics will provide near- and long-term solutions.

Analysis of errors enacted by surgical trainees during skills training courses

BACKGROUND

Despite the emphasis on medical error as a major cause of hospital morbidity and mortality, there has been little published work on errors committed by trainees. This issue is particularly relevant to the training of surgeons and was addressed by our study.

METHODS

Sixty simulated laparoscopic cholecystectomies performed on restructured pig tissue models by 60 surgical trainees provided the study material. The unedited videotapes were analyzed by observational HRA of the component steps of the procedures. Ten generic forms of observable error types were used to categorize patterns of failure. Error probabilities with specific instruments were also calculated.

RESULTS

A total of 1067 errors were identified by observational HRA: 331 consequential and 736 without consequence (ie, total error rate of 18 [SD +/- 10]) per procedure. The study documented a wide variation in the number of errors between the 60 trainee surgeons. The important underlying factors for the trainee errors were (1) omission of important steps, (2) execution of steps in the wrong sequence, and (3) use of excessive force. These 3 errors accounted for 92% of consequential errors.

CONCLUSIONS

This study has shown that trainees vary considerably in their propensity to commit errors. This variability indicates that the surgical training in component skills for laparoscopic surgery should be flexible and individualized. Three mechanisms account for the majority of errors and indicate that skills training in surgery has to be structured, menu driven, and tailored to individual needs.

Identification and categorization of technical errors by Observational Clinical Human Reliability Assessment (OCHRA) during laparoscopic cholecystectomy

HYPOTHESIS

Surgical operative performance benefits from analysis of the mechanisms underlying technical errors committed during surgery.

DESIGN

Prospective study using the Observational Clinical Human Reliability Assessment (OCHRA) system and complete unedited videotapes of the operations.

SETTING

Three National Health Service hospitals within the United Kingdom.

PATIENTS

Two hundred consecutive patients with symptomatic gallstone disease.

INTERVENTIONS

Elective laparoscopic cholecystectomy for symptomatic gallstone disease by surgeons, who were blind to the nature and objectives of the study, using their usual operative technique.

MAIN OUTCOME MEASURES

Surgical consequential and inconsequential operative errors.

RESULTS

The analysis of 38 062 steps of the 200 laparoscopic cholecystectomies performed by 26 surgeons identified 2242 errors. The mean +/- SD total, inconsequential, and consequential errors per surgical procedure were 11.0 +/- 8.0, 8.0 +/- 6.0, and 4.0 +/- 3.0, respectively. Dissection of the Calot triangle (second task zone of the operation) incurred more total errors (6.5 +/- 5.4) compared with the first (2.9 +/- 2.8, P<.001) and third (5.1 +/- 3.9, P<.05) task zones. This translated to a higher error probability (6.9% vs 3.5% for the first and 5.5% for third task zones). The combined sharp and blunt dissection method had fewer errors than the blunt/teasing dissection technique (9.45 +/- 7.6 vs 13.9 +/- 7.3, P<.001) although different surgeons were involved. The most serious consequences were encountered during dissection with the electrosurgical hook knife.

CONCLUSION

This study has confirmed that the Observational Clinical Human Reliability Assessment system provides a comprehensive objective assessment of the quality of surgical operative performance by documenting the errors, the stage of the operation in which errors are enacted most frequently, and where these errors have serious consequences (hazard zones).

Efficacy and safety of telmisartan vs. losartan in control of mild-to-moderate hypertension: a multicentre, randomised, double-blind study

This multicentre, randomised, double-blind, double-dummy, parallel-group study compared the efficacy and safety of telmisartan with those of losartan after 8 weeks' treatment. In total, 330 patients with mild-to-moderate hypertension (systolic blood pressure [SBP] <180 mmHg; diastolic blood pressure [DBP] 95-109 mmHg) were randomly assigned to receive once-daily treatment with telmisartan 40 mg (n = 164) or losartan 50 mg (n = 166). After 4 weeks' treatment, if a patient's DBP was > or = 90 mmHg, the dose was increased to telmisartan 80 mg or losartan 100 mg, respectively. The results show that mean trough seated blood pressure was reduced significantly more in the telmisartan group than that in the losartan group (SBP 12.5 mmHg vs. 9.4 mmHg, p = 0.037; DBP 10.9 mmHg vs. 9.3 mmHg, p = 0.030). The overall DBP response rate (reduction from baseline in mean seated DBP > or = 10 mmHg and/or a mean seated DBP <90 mmHg) at the end of the study in the telmisartan group was higher than that in losartan group (70.1% vs. 58.7%, p = 0.020). At both the low and high doses, the DBP response rates for telmisartan were significantly higher than those for losartan (telmisartan 40 mg vs. losartan 50 mg: 46.3% vs. 32.5%, p = 0.010; telmisartan 80 mg vs. losartan 100 mg: 79.3% vs. 65.3%, p = 0.008). Adverse events with the two treatments were comparable (telmisartan vs. losartan 23.2% vs. 22.9%, p = 0.952). Most events were mild in intensity and abated within 72 h. Thus, telmisartan 40 mg or 80 mg administered once daily can reduce SBP and DBP effectively and safely.

Analysis of technical surgical errors during initial experience of laparoscopic pyloromyotomy by a group of Dutch pediatric surgeons

BACKGROUND

The adoption of laparoscopic pyloromyotomy (LPM) by pediatric surgeons has been limited due to concerns about long execution times and higher-than-expected morbidity. The aim of the present study was to examine the performance of LPM by pediatric surgeons during the initial stages of their experience.

METHODS

Complete videotapes of 50 early LPM performed in one hospital were subjected to Observational Clinical Human Reliability Analysis (OCHRA) by an independent team.

RESULTS

This series had a total morbidity of 6% (one intraoperative bleed, one gastric perforation, one incomplete pyloromyotomy). Using OCHRA, we identified 77 consequential and 233 inconsequential errors (mean of 6 +/- 5.4 per operation, 16.7% total error probability) during an average operative time of 29.8 min. Eighty percent of the errors were of the execution type. A high probability of error was observed with the use of the following key instruments: holding graspers (68%), retractable blade (79%), and splitting forceps (77%). The OCHRA system confirmed that task III was the hazard zone for LPM. Excessive force (task III) resulted in gastric perforation and bleeding from the pyloric mass. Movement in the wrong direction and misorientation in tissue planes were the external error modes underlying misaligned cuts of the pyloric mass and poor tissue splitting (task zones II and III).

CONCLUSIONS

This early series of LPM was associated with an appreciable execution error rate, largely due to the poor functionality of the specific instruments used for the procedure. Human factors identified by the external error modes played a subsidiary but important role, underscoring the importance of skills training and experience (proficiency-gain curve).

RIP kinase is involved in arsenic-induced apoptosis in multiple myeloma cells

These studies explore the molecular effect of arsenicals on MM cells. Freshly isolated cells derived from patients with advanced, chemo-refractory myeloma as well as human myeloma cell lines, ARP-1, RPMI-8226 and H929 were exposed to the organic arsenical melarsoprol and to the inorganic compound AT. Both agents potently induced apoptosis in myeloma cells. Exposure to 1-5 microM AT or melarsoprol for 6 hours suppressed NF-kappa B DNA binding and enhanced of c-Jun kinase (JNK) activity. Arsenic also activated caspase-3 resulting in the cleavage of poly (ADP-ribose) polymerase (PARP) and Fas/TNF alpha related receptor interacting protein (RIP). In contrast to reported observations in acute promyelocytic leukemia, myeloma cell apoptosis was not associated with either the downregulation of Bcl-2 protein or with alterations in the expression of other Bcl-2 family members, Bax, Bak, Bag, and Bcl-xl. This study first shows that arsenic induces apoptotic signaling in MM through the cleavage of TNF alpha related receptor interacting protein (RIP). RIP is a key downstream protein in FasL/ TNF alpha /TRAIL induced apoptosis and a major antiapoptotic adaptor of pathways through NF-kappa B and JNK. RIP has not been previously characterized in myeloma. This study supports the hypothesis that arsenicals share common mediators (RIP, NF-kappa B, PARP, caspase-3) with death receptor induced apoptosis. These studies provide an important insight into the molecular mechanism of AT induced apoptosis and can be used in the development of adjuvant therapy for MM, presently an incurable disease.

The roles of interleukin-18 in collagen-induced arthritis in the BB rat

Interleukin (IL)-18 is a member of the IL-1 cytokine family. Its expression is increased in rheumatoid arthritis synovium, and its proinflammatory effects have been demonstrated in experimental models of murine arthritis. Here, we investigate the actions of varying doses of recombinant rat IL-18 (rIL-18) on the course of type II collagen-induced arthritis (CIA) in BB rats, including clinical and immune events, plus splenic cytokine production. Small doses of rIL-18 (10 and 50 microg/rat) administered intraperitoneally (i.p.) increased arthritis incidence and severity (P < 0.01) when a low-potency CII preparation was used for immunization. IgG1 and IgG2a anti-CII antibody levels were significantly greater in rats given 10 and 50 microg rIL-18 doses than controls. rIL-18 significantly increased levels of proinflammatory cytokines [interferon (IFN)-gamma, IL-2, tumour necrosis factor (TNF)-alpha and IL-6] produced by splenocyte cultures. Larger doses of rIL-18 (300 microg/rat) suppressed arthritis and immunity. To ascertain whether the pro-arthritic effects of IL-18 could be attenuated, rats were treated with neutralizing rabbit anti-rIL-18 IgG before immunization with a high-potency CII preparation. When given serially for 3 weeks, the incidence and severity of CIA, in addition to anti-CII IgG2a and splenic IL-6 and IFN-gamma production, were all significantly reduced. Similar results were noted when antibody was given twice, just before arthritis onset. These results demonstrate that IL-18 plays an important proinflammatory role in the pathogenesis of CIA which is achieved, in part, by an immunostimulatory action. Neutralizing endogenous IL-18 with antibodies attenuated CIA, CII immunity and cytokine responses. These studies support the use of IL-18 antagonists as treatments for inflammatory arthritis.

Efficacy of modified recombinant type II collagen in modulating autoimmune arthritis

OBJECTIVE

Previous studies have shown that an analog peptide of the immunodominant T cell determinant of type II collagen (CII), i.e., CII(256-276)(N(263), D(266)), was able to suppress the immune response to CII and the development of arthritis in DR1-transgenic mice. The present study tested the hypothesis that introduction of the same amino acid substitutions into full-length CII might improve the efficacy of the mutant collagen in achieving suppression of autoimmune arthritis.

METHODS

Using recombinant technology, full-length CII was modified, while the native conformation was retained. Two point mutations were introduced within the immunodominant T cell determinant to convert the F(263) to N and E(266) to D, using a baculovirus expression system that has previously been utilized in the production of recombinant CII (rCII).

RESULTS

The mutant rCII(N(263), D(266)) was capable of reducing the incidence and severity of arthritis as well as the antibody response to CII when administered to DR1-transgenic mice that display susceptibility to collagen-induced arthritis. More importantly, it was significantly more effective than the synthetic analog peptide, CII(256-276)(N(263), D(266)). Its mechanism of suppression may be explained by the secretion of predominantly Th2 cytokines by the T cells immunized with rCII(N(263), D(266)). Administration of rCII(N(263), D(266)) was ineffective in suppressing arthritis in IL4(-/-) mice, suggesting that the profound suppressive effects of rCII(N(263), D(266)) were mediated through the production of interleukin-4.

CONCLUSION

These findings describe a promising specific immunotherapy for patients with DR1-mediated autoimmunity to CII.

Absence of Interferon-γ–Inducible Gene IGTP Does Not Significantly Alter the Development of Chagasic Cardiomyopathy in Mice Infected with Trypanosoma cruzi (Brazil Strain)

Interferon-gamma (IFN-gamma) contributes to host resistance during acute infection with Trypanosoma cruzi, the causative agent of Chagas' disease. Inducibly expressed guanosine triphosphatase (IGTP), a 48-kDa guanosine triphosphatase (GTPase), is a member of a family of GTPase proteins inducibly expressed by IFN-gamma. The expression pattern of IGTP suggests that it may mediate IFN-gamma-induced responses in a variety of cell types. IGTP has been demonstrated to be important for control of Toxoplasma gondii infection but not for resistance against Listeria monocytogenes. We evaluated the role of IGTP in development of chronic chagasic cardiomyopathy in IGTP null mice and C57X129sv (wild type [WT]) mice infected with the Brazil strain for 6 mo. There was no significant difference in parasitemia or cardiac histopathology between null and WT mice. Right ventricular remodeling was observed in infected IGTP null mice, suggesting that IGTP does not significantly alter the course of T. cruzi infection.

Lower blood glucose, hyperglucagonemia, and pancreatic alpha cell hyperplasia in glucagon receptor knockout mice

Glucagon, the counter-regulatory hormone to insulin, is secreted from pancreatic alpha cells in response to low blood glucose. To examine the role of glucagon in glucose homeostasis, mice were generated with a null mutation of the glucagon receptor (Gcgr(-/-)). These mice display lower blood glucose levels throughout the day and improved glucose tolerance but similar insulin levels compared with control animals. Gcgr(-/-) mice displayed supraphysiological glucagon levels associated with postnatal enlargement of the pancreas and hyperplasia of islets due predominantly to alpha cell, and to a lesser extent, delta cell proliferation. In addition, increased proglucagon expression and processing resulted in increased pancreatic glucogen-like peptide 1 (GLP-1) (1-37) and GLP-1 amide (1-36 amide) content and a 3- to 10-fold increase in circulating GLP-1 amide. Gcgr(-/-) mice also displayed reduced adiposity and leptin levels but normal body weight, food intake, and energy expenditure. These data indicate that glucagon is essential for maintenance of normal glycemia and postnatal regulation of islet and alpha and delta cell numbers. Furthermore, the lean phenotype of Gcgr(-/-) mice suggests glucagon action may be involved in the regulation of whole body composition.

Increased B-type natriuretic peptide (BNP) level is a strong predictor for cardiac dysfunction in intensive care unit patients

Patients admitted to an Intensive Care Unit (ICU) frequently have underlying cardiac dysfunction. Early interventions are sometimes difficult to initiate because of diagnostic uncertainty as to whether cardiac failure is present As B-type natriuretic peptide (BNP) has been shown to be increased in cardiac dysfunction, we sought to demonstrate whether BNP can be used as a screening tool for cardiac dysfunction in patients admitted to ICU. All patients admitted to a combined medical and surgical ICU over a four-week period were included in the study. BNP was measured on the point of admission using a hand-held meter. Clinicians were blinded from the measurement when diagnoses were made as to whether or not the patients had clinically significant cardiac dysfunction. Patients with cardiac dysfunction had a significantly higher level of BNP when compared to the non-cardiac dysfunction group: 516 +/- 385 pg/ml (n = 26) v 67 +/- 89 pg/ml (n = 58) (P < 0.0001) A BNP cut-off value at 144 pg/ml exhibited a 92% sensitivity, 86% specificity and 96% negative predictive value. The sensitivity improved to 96% when the analysis was confined to patients > or = 55 years. At this cut-off value, BNP is a strong predictor of cardiac dysfunction. BNP measurement offers a rapid and affordable way to screen for cardiac dysfunction in patients admitted to ICU. An increased BNP level warrants further cardiac investigations so as to implement early interventions for cardiac decompensation in ICU patients.

Peptide-induced suppression of collagen-induced arthritis in HLA-DR1 transgenic mice

OBJECTIVE

To identify peptides capable of altering the immune response to type II collagen (CII) in the context of HLA-DR.

METHODS

Immunizing mice transgenic for the human HLA-DRB1*0101 immune response gene with CII elicits an arthritis (collagen-induced arthritis [CIA]) that resembles rheumatoid arthritis. We have previously identified an immunodominant determinant of CII, CII (263-270), recognized by T cells in the context of DR1. To produce synthetic peptides with the potential of disrupting the DR1-restricted immune response, synthetic analog peptides were developed that contain site-directed substitutions in critical positions. These peptides were used to treat CIA in DR1 transgenic mice.

RESULTS

An analog peptide, CII (256-276, N(263), D(266)), that inhibited T cell responses in vitro, was identified. When DR1 mice were coimmunized with CII and CII (256-276, N(263), D(266)), the incidence and severity of arthritis were greatly reduced, as was the antibody response to CII. Moreover, CII (256-276, N(263), D(266)) was effective in down-regulating the immune responses to CII and arthritis, even when administered 2 weeks following immunization with CII. Spleen and lymph node cells from CII-immunized mice cultured with CII (256-276, N(263), D(266)) in vitro produced increased amounts of interleukin-4 (IL-4) compared with cells cultured with the wild-type peptide, CII (256-276). Furthermore, CII (256-276, N(263), D(266)) was incapable of preventing arthritis in DR1 IL-4(-/-) mice (genetically deficient in IL-4).

CONCLUSION

These data establish that CII (256-276, N(263), D(266)) is a potent suppressor of the DR-mediated immune response to CII. Its effect is mediated, at least in part, by IL-4. These experiments represent the first description of an analog peptide of CII recognized by T cells in the context of a human major histocompatibility complex molecule that can suppress autoimmune arthritis.

The role of IL-4 in regulation of murine collagen-induced arthritis

Collagen-induced arthritis (CIA) is a murine model of autoimmune-mediated polyarthritis. CIA can be prevented by the administration (intravenously) of CII, inducing regulatory CD4+ T cells which produce Th2 cytokines. However, the relative importance of IL-4 in suppressing arthritis remains unclear. To address this question, a neutralizing monoclonal antibody to IL-4 was given to mice treated with tolerized, CII-specific cells. The antibody significantly reversed the expected suppression of arthritis. Moreover, CII administered intravenously to DBA/1 IL4-/- mice (developed by backcrossing C57B1/6 IL4-/- to wild-type DBA/1 mice) was completely ineffective in suppressing disease. These data support the importance of IL-4 in the regulation of autoimmune arthritis. Compensatory increases in mRNA message for other Th2 cytokines were observed, but they did not restore suppression of arthritis. Antibodies to CII, mostly IgG2a, were increased in IL4-/- mice. These studies represent a unique opportunity to analyze the role of IL-4 and its absence on an autoimmune murine model of arthritis.

[Analysis of the parkin gene deletion mutations in Chinese patients with Parkinson's disease]

OBJECTIVE

Clarify parkin gene deletion mutations at exons 3 to 7 in Chinese patients with Parkinson's disease (PD) and analyze them together with the clinical features of PD.

METHODS

DNA was extracted from peripheral blood of 33 sporadic PD patients and 6 familial PD patients. Deletion mutations of parkin gene were identified by PCR amplification and agarose gel electrophoresis. The clinical data were analyzed together with the above information.

RESULTS

Of the 33 sporadic PD patients, 1 had exons 5 and 7 deletion, 2 had exon 7 deletion. The age of onset was 46, 48, 50 respectively. In the 6 familial PD patients, 1 had exon 5 deletion. The inheritance pattern in this patient was autosomal recessive and onset of the patient was 60. All of the patients who had parkin gene deletion mutations had tremor, rigidity and bradykinesia, but athetosis was not found. In addition, deletion mutations of parkin gene at exons 3, 4 and 6, were not found.

CONCLUSION

There are deletion mutations of parkin gene at exons 5 and 7 in Chinese PD patients.