Successful surgical salvage of partial pancreatic allograft thrombosis

BACKGROUND

Venous thrombosis remains an important cause of pancreatic graft loss. Nevertheless, reports are scarce of treatment alternatives to complete graft removal. We describe a case of surgical salvage of a partial pancreatic graft thrombosis.

METHODS

We used descriptive retrospective analysis.

RESULTS

A 36-year-old patient with juvenile-onset diabetes mellitus and previous living related renal transplant received a cadaveric pancreas transplant in the right iliac fossa with enteric exocrine drainage and standard vascular anastomosis. Two days after discharge from the hospital, he presented with severe right upper quadrant pain, nausea, vomiting, fever, and leukocytosis. He was taken to the operating room for exploration. The tail of the pancreas, which was kinked under the gallbladder, was necrotic and excised. The remainder of the pancreas looked normal. The patient recovered well from surgery and was discharged home 7 days later.

CONCLUSIONS

Partial pancreatectomy is an acceptable surgical alternative for incomplete graft thrombosis.

Sensitivity of cyanobacterial antenna, reaction center and CO2 assimilation transcripts and proteins to moderate UVB: light acclimation potentiates resistance to UVB

We tested the hypothesis that cyanobacterial cells have sufficient acclimation potential to tolerate UVB when it is applied in a natural quantum ratio to growth photosynthetically active radiation (PAR). We grew Synechococcus under 50 (Low) or 300 (High) micromol PAR m(-2) x s(-1) and then exposed the cells to 0.125 (Low) or 0.75 (High) micromol UVB m(-2) x s(-1). The PAR:UVB quantum ratios were near natural for both the Low-PAR:Low-UVB and the High-PAR:High-UVB treatments, but UVB was in excess of typical aquatic PAR:UVB for Low-PAR:High-UVB treatments. The cellular light history determined the UVB responses of Synechococcus. High-PAR cells initially had fewer cpc transcripts encoding phycocyanin, lower phycocyanin content, and more psbAII/AIII transcripts encoding the D1:2 photosystem II (PSII) protein isoform. Higher PAR potentiated them to tolerate an appropriate UVB level without short-term inhibition of PSII or growth. Low-PAR cells rapidly altered psbAII/AIII and cpc gene expression and tolerated appropriate Low UVB. Low-PAR:High-UVB cells, in contrast, suffered short-term inhibition of PSII and growth. In all treatments UVB induced transient loss of cpc transcripts, possibly to free resources for psbAII/AIII expression, which is important for UVB resistance. The drop in cpc transcripts was not part of a general shock response because rbcL transcript pools were stable upon UVB exposure.

The genetic diversity of Brazilian Trypanosoma cruzi isolates and the phylogenetic positioning of zymodeme 3, based on the internal transcribed spacer of the ribosomal gene

There is a high level of genetic diversity among the clinical isolates of the taxon Trypanosoma cruzi. The results of recent studies on well defined gene loci have revealed that T. cruzi can be divided into two major phylogenetic lineages, designated T. cruzi I and T. cruzi II. Further intra-lineage polymorphisms were explored, in clinical isolates from five representative regions of Brazil, using the internal transcribed spacers that flank the 5.8S ribosomal RNA gene. These regions were amplified in a PCR and the products were digested with six restriction enzymes before being subjected to RFLP analysis in polyacrylamide gels. The results were used to construct a complex evolutionary tree, in which the isolates were clustered into two major phylogenetic lineages with a low level of similarity. To investigate the evolutionary relationships between the isolates, the PCR products were cloned and sequenced. The results of the subsequent phylogenetic analysis confirmed the presence of the two major groups of T. cruzi and showed that zymodeme 3, a third iso-enzymatic sub-group, is closer to T. cruzi I than to T. cruzi II.

The Victorian CPAP program: is there a need for additional education and support?

BACKGROUND

The Victorian Continuous Positive Airways Pressure (CPAP) Program provides CPAP services to financially disadvantaged individuals with moderate to severe sleep apnoea.

AIMS

To evaluate health outcomes in patients referred to the pilot program in order to: (i) assess the magnitude of health benefit from treatment in this highly selected population and (ii) identify patient characteristics or factors related to service provision that may influence outcome.

METHODS

We adopted a simple before-after research design. Patients who were referred to the program were recruited from five sleep centres. Questionnaires were administered at baseline and 1 and 3 months after commencing CPAP. Generic and disease-specific quality of life were assessed using the MOS 36-Item Short-form Health Survey and the Sleep Apnoea Quality-of-life Index, respectively. Subjective daytime sleepiness was measured using the Epworth Sleepiness Scale and the Sleep-Wake Activity Inventory.

RESULTS

Of the 68 subjects enrolled in the study, 59 were available for follow up. There were significant improvements in daytime sleepiness (P < 0.0005). Treatment-related symptoms had a negative impact on overall disease-specific quality of life, however there were significant improvements in all other domains of disease-specific quality of life (P < 0.0005). Improvements in generic quality of life were small but statistically significant (P < 0.05). Hospital, disease severity, baseline sleepiness, gender and CPAP-machine type were not predictors of outcome (P > 0.05).

CONCLUSION

This review of the Victorian CPAP Program identified significant improvements in subjective daytime sleepiness and quality of life, despite the negative impact of treatment-related symptoms. Future research should explore whether services can be modified to help reduce the impact of treatment-related side-effects.

Measurement variability in sleep disorders medicine: the Victorian experience

BACKGROUND

Surveys of laboratories in North America have documented significant diversity in the working definitions used for reporting respiratory events in sleep studies.

AIM

To assess sources of variability in the measurement of sleep-disordered breathing (as defined by the Apnoea-Hypopnoea Index) between sleep laboratories in Victoria, Australia.

METHODS

A self-complete written questionnaire was constructed following literature review and interviews with staff at three separate sleep laboratories. The survey was sent to all laboratories listed in Victoria by the Australasian Sleep Association. The first part of the survey related to the type of equipment used to record sleep and other variables during overnight polysomnography and the second part related to the definitions and methods used to report results.

RESULTS

Seventeen out of 18 laboratories returned the surveys. There were variations identified in the types of sensors used to measure particular signals. There were also inconsistencies identified in the criteria used to score arousals, apnoeas and hypopnoeas by different laboratories. The variability was greatest for hypopnoea definitions.

CONCLUSIONS

There is considerable variation in the methods used to measure and define sleep-disordered breathing between sleep laboratories in Victoria. The extent to which these variations influence the comparability of reported results between laboratories requires further evaluation. The survey findings may assist the process of developing and implementing local guidelines for the performance and reporting of polysomnography.

Seasonal changes in chlorophyll fluorescence quenching and the induction and capacity of the photoprotective xanthophyll cycle in Lobaria pulmonaria

Lobaria pulmonaria (L.) Hoffm. survives large changes in ambient light and temperature between winter and summer in temperate deciduous forests. Potential photosystem II (PSII) electron transport, measured at 20°C using chlorophyll fluorescence analysis, was consistent in thallus samples taken in March and August from a temperate deciduous forest, while the potential for nonphotochemical quenching (NPQ) was higher in March than in August. NPQ was, however, similar in March and August in a population from a coniferous site with a permanently closed canopy. Thalli measured at a typical March field temperature showed a depression of PSII electron transport, qp and gross CO2 uptake and a rise in realized NPQ. Xanthophyll cycle pigments were more abundant in the March than in the August samples in the deciduous forest populations but did not change significantly in the permanently closed-canopy population. In August, relatively low NPQ correlated with xanthophyll pool size in the deciduous forest samples. The more intense NPQ derived from low temperature and low CO2-electron demand in the March samples, however, was not correlated with xanthophyll pool size. Thus, most of the NPQ observed in the high light exposure March samples was not explained by variation in xanthophyll pool size.Key words: carotenoids, excitation quenching, lichen, nonphotochemical quenching, PSII electron transport.

A randomized trial of peak-flow and symptom-based action plans in adults with moderate-to-severe asthma

OBJECTIVE

Peak flow meters (PFM) continue to be recommended as an important part of asthma self-management plans. It remains unclear if there is an advantage in using PFM in people with moderate-to severe asthma who are not poor perceivers of bronchoconstriction.

METHODOLOGY

Prospective, randomized controlled trial of 134 adults with moderate-to-severe asthma who did not have evidence of poor perception of bronchoconstriction on histamine challenge testing, who were recruited from inpatients and outpatients of a university teaching hospital. Comparison was made over 12 months of the effectiveness of written action plans using either peak flow monitoring or symptoms to guide management. Subjects were contacted at monthly intervals by telephone for reinforcement and evaluation of use of the action plans, and to provide ongoing education. Spirometry and PD20 histamine were measured at 3-monthly intervals. Measures of health care utilization and morbidity (asthma exacerbations; hospitalizations; emergency department (ED) visits; days absent from work or school due to asthma; medication use and a self-rating of asthma severity) were made monthly. A psychosocial questionnaire (attitudes and beliefs, state-trait anxiety, denial) was given at entry and at 12-months or at withdrawal from the study.

RESULTS

There were significant improvements for both groups for hospitalizations, ED visits, days off from school or work, and PD20 histamine, but no between-group differences. Appropriate use of action plans was 85% in the symptoms group and 86% in the PFM group. For all subjects, those who subsequently had an ED visit had significantly higher levels of denial (P=0.04) and lower scores for self-confidence (P=0.04), compared to those who did not have an ED visit.

CONCLUSIONS

Use of written action plans, combined with regular contact to reinforce self-management, improved airway reactivity and reduced health care utilization. However, use of PFM was not superior to symptom-based plans.

Kinetoplast DNA minicircles of phloem-restricted Phytomonas associated with wilt diseases of coconut and oil palms have a two-domain structure

We report the cloning and sequencing of the first minicircle from a phloem-restricted, pathogenic Phytomonas sp. (Hart 1) isolated from a coconut palm with hartrot disease. The minicircle possessed a two-domain structure of two conserved regions, each containing three conserved sequence blocks (CSB). Based on the sequence around CSB 3 from Hart 1, PCR primers were designed to allow specific amplification of Phytomonas minicircles. This primer pair demonstrated specificity for at least six groups of plant trypanosomatids and did not amplify from insect trypanosomatids. The PCR results were consistent with a two-domain structure for other plant trypanosomatids.

Hope and harm: a delicate balance. Death and dying in multicultural Australia

Australia's cultural diversity poses challenges to healthcare professionals, particularly in caring for dying people. Different cultures have different attitudes to the role of the doctor, patient autonomy and disclosure of diagnosis and prognosis. Doctors need to recognise the cultural and spiritual needs of patients and their families.

Two sequence classes of kinetoplastid 5S ribosomal RNA gene revealed among bodonid spliced leader RNA gene arrays

The spliced leader RNA genes of Bodo saltans, Cryptobia helicis and Dimastigella trypaniformis were analyzed as molecular markers for additional taxa within the suborder Bodonina. The non-transcribed spacer regions were distinctive for each organism, and 5S rRNA genes were present in Bodo and Dimastigella but not in C. helicis. Two sequence classes of 5S rRNA were evident from analysis of the bodonid genes. The two classes of 5S rRNA genes were found in other Kinetoplastids independent of co-localization with the spliced leader RNA gene.

Seasonal changes in temperature and light drive acclimation of photosynthetic physiology and macromolecular content in Lobaria pulmonaria

Lobaria pulmonaria (L.) Hoffm. is an epiphytic lichen common to temperate deciduous forests where it copes with large changes in temperature and light levels through repeated annual cycles. Samples of L. pulmonaria were taken from a deciduous forest in southeastern Canada at 35-day intervals from February 1999 to February 2000 and also from a rare population in an evergreen forest in March and August 1999. At field-ambient temperatures and light levels, the realised photosystem II (PSII) electron transport was low both in the summer and winter, with transient peaks in the spring and autumn. In contrast, the seasonal pattern of potential electron transport measured at a fixed 20 degrees C peaked in winter, showing the importance of temperature in driving photosynthesis to low levels in the winter despite an acclimation of electron-transport potential to exploit the high ambient light. Realised gross CO2 uptake was correlated with PSII electron transport at mechanistically plausible rates at all sampling sites in the summer but not in the winter, indicating electron diversion away from CO2 fixation in the winter. Chlorophyll content was highest in the dark summer months. The amount of ribulose-1,5-bisphosphate carboxylase-oxygenase (RuBisCO) large subunit (LSU) was highest in spring. Changes in the level of this hyperabundant protein and in the activity of PSII maintained a relatively constant rate of maximum CO2 uptake per RuBisCO LSU from April through November, despite great changes in the seasonal light and temperature. L. pulmonaria acclimates between light and temperature stress in the winter months to light-limitation in the dark summer months. Transition intervals in the spring and autumn, with warm, bright and wet conditions, are likely the most amenable times for growth.

Burnout among American surgeons

BACKGROUND

The long-term consequences of stress on the surgeon are unknown. One manifestation of stress is burnout. The purpose of this study was to measure the prevalence of burnout in actively practicing American surgeons.

METHODS

The Maslach Burnout Inventory and a questionnaire of our own design were sent to 1706 graduates of various University of Michigan surgical residencies (1222) and members of the Midwest Surgical Association (484). The response rate was 44%. Responses from 582 actively practicing surgeons were the sample used for analysis.

RESULTS

Thirty-two percent of actively practicing surgeons showed "high" levels of emotional exhaustion, 13% showed "high" levels of depersonalization, and 4% showed evidence for low personal accomplishment. Younger surgeons were more susceptible to burnout (r = -0.28, P <.01). Burnout was not related to caseload, practice setting, or percent of patients insured by a health maintenance organization. Important etiologic factors were a sense that work was "overwhelming" (r = 0.61, P <.01), a perceived imbalance between career, family, and personal growth (r = -0.56), P <.01), perceptions that career was unrewarding (r = -0.42, P <.01), and lack of autonomy or decision involvement (r = -0.39, P <.01). A strong association was noted between burnout elements and a desire to retire early (r = 0.50, P <.01).

CONCLUSIONS

Burnout is an important problem for actively practicing American surgeons. These data could be used to modify existing surgical training curricula or as an aid to surgical leadership when negotiating about the surgical work environment.

Impact of different criteria for defining hypopneas in the apnea-hypopnea index

OBJECTIVES

To explore the effect of using different scoring criteria for hypopneas in the scoring of polysomnographic studies: (1) by estimating the level of agreement between apnea-hypopnea index (AHI) scores derived from different scoring methods, and (2) by examining the effect on the point prevalence of disease using different threshold values of the AHI.

DESIGN

Retrospective analysis of 48 diagnostic polysomnographic records.

SETTING

Tertiary-hospital sleep-disorders clinic.

MEASUREMENTS

AHIs were derived from three different methods for scoring hypopneas. The hypopnea definitions used incorporated different combinations and threshold values of respiratory signal changes in addition to differences in the requirement for associated oxygen desaturation or arousal. The level of agreement between different scoring methods was assessed by constructing Bland-Altman plots and calculating intraclass correlation coefficients (ICCs). kappa statistics were used to assess agreement between the different methods using varying thresholds of AHI to categorize sleep apnea (AHI > 5, AHI > 15, and AHI > 20).

RESULTS

The random-effects ICC for the three methods was 0.89, suggesting that the different scoring methods tended to rank patients fairly consistently. However, the point prevalence of disease estimated by using different thresholds of AHI was found to vary depending on the method used to score sleep studies (kappa, 0.30 to 0.95).

CONCLUSIONS

These findings have implications for case finding, population-prevalence estimates, and grading of disease severity for access to government-funded continuous positive airway pressure services. Guidelines for standardizing the measurement and reporting of sleep studies in clinical practice should be implemented.

Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy

BACKGROUND

Laparoscopic live donor nephrectomy for renal transplantation is being performed in increasing numbers with the goals of broadening organ supply while minimizing pain and duration of convalescence for donors. Relative advantages in terms of recovery provided by laparoscopy over standard open surgery have not been rigorously assessed. We hypothesized that laparoscopic as compared with open surgical live donor nephrectomy provides briefer, less intense, and more complete convalescence.

METHODS

Of 105 volunteer, adult, potential living-renal donors interested in the laparoscopic approach, 70 were randomly assigned to undergo either hand-assisted laparoscopic or open surgical live donor nephrectomy at a single referral center. Objective data and subjective recovery information obtained with telephone interviews and validated questionnaires administered 2 weeks, 6 weeks, and 6-12 months postoperatively were compared between the 23 laparoscopic and 27 open surgical patients.

RESULTS

There was 47% less analgesic use (P=0.004), 35% shorter hospital stay (P=0.0001), 33% more rapid return to nonstrenuous activity (P=0.006), 23% sooner return to work (P=0.037), and 73% less pain 6 weeks postoperatively (P=0.004) in the laparoscopy group. Laparoscopic patients experienced complete recovery sooner (P=0.032) and had fewer long-term residual effects (P=0.0015).

CONCLUSIONS

Laparoscopic donor nephrectomy is associated with a briefer, less intense, and more complete convalescence compared with the open surgical approach.

Durability of response to a targeted intervention to modify clinician transfusion practices in a major teaching hospital

OBJECTIVES

To determine the durability of a successful intervention to modify clinician transfusion practices, and to compare current transfusion practices in the "intervention" hospital with those in a hospital with no intervention.

DESIGN

Prospective, descriptive study.

SETTING

Two major metropolitan teaching hospitals--Royal Melbourne Hospital and Western Hospital, Footscray.

SUBJECTS

Consecutive patient transfusion episodes for red cells, platelets and fresh frozen plasma (FFP).

OUTCOME MEASURES

Appropriateness of transfusion according to intervention guidelines; comparison of inappropriate transfusion rates before the intervention, immediately after the intervention and 3 years after the intervention. Comparison of inappropriate transfusion rates in intervention and non-intervention hospitals.

RESULTS

Inappropriate transfusion rates 3 years after the intervention were 20% for red cells, 27% for platelets, and 43% for FFP. These were significantly higher than equivalent rates reported immediately after the intervention. Inappropriate transfusion rates at the non-intervention hospital were comparable (26% for red cells, 36% for platelets and 52% for FFP).

CONCLUSION

Appropriate clinician transfusion practices have proven difficult to sustain 3 years after hospital guideline generation and promotion. A "gate-keeping" role by hospital blood bank staff proved impractical in the long term.

Diplonema spp. possess spliced leader RNA genes similar to the Kinetoplastida

The phylogenetic placement of the genus Diplonema in relation to fellow phylum members Euglena and Trypanosoma has been uncertain. The spliced leader RNA gene, present in the euglenids and kinetoplastids in distinct forms, was a potential target for resolving this question. The first indication supporting a closer relationship to the kinetoplastids was the recognition of potential spliced leader RNA exon sequences in the genomic DNA of two Diplonema isolates. Examination of total cell RNA revealed transcripts in the anticipated size range at approximately 120 and 130 nt. Specific PCR amplification of a spliced leader RNA gene repeat was performed. The hallmark features of the kinetoplastid-type spliced leader RNA, specifically the 39-nt exon, splice-donor site, Sm-binding site and poly-T tract and the potential to form the requisite stem-loop structures, were found. Diplonema spp. are different from the kinetoplastids by virtue of C residues at positions 4 and 18 in the exon. While the intergenic spacer regions varied in size, each contained the complete sequence or remnants of a 5S ribosomal RNA gene. Possession of a functional spliced leader RNA gene of the kinetoplastid variety in Diplonema supports a closer evolutionary relationship with this group than with the euglenids.

The spliced leader RNA gene array in phloem-restricted plant trypanosomatids (Phytomonas) partitions into two major groupings: epidemiological implications

The arbitrary genus Phytomonas includes a biologically diverse group of kinetoplastids that live in a wide variety of plant environments. To understand better the subdivisions within the phytomonads and the variability within groups, the exon, intron and non-transcribed spacer sequences of the spliced leader RNA gene were compared among isolates of the phloem-restricted members. A total of 29 isolates associated with disease in coconut, oil palm and red ginger (Alpinia purpurata, Zingibreaceae) were examined, all originating from plantations in South America and the Caribbean over a 12-year period. Analysis of non-transcribed spacer sequences revealed 2 main groups, I and II; group II could be further subdivided into 2 subgroups, IIa and Ilb. Three classes of spliced leader (SL) RNA gene were seen, with SLI corresponding to group I, SLIIa to group lIa, and SLIIb to group IIb. Two isolates showed some characteristics of both major groups. Group-specific oligonucleotide probes for hybridization studies were tested, and a multiplex amplification scheme was devised to allow direct differentiation between the 2 major groups of phloem-restricted Phytomonas. These results provide tools for diagnostic and molecular epidemiology of plant trypanosomes that are pathogenic for commercially important flowers and palms.

Renal transplantation at the University of Michigan 1964 to 1999

The Michigan Kidney Transplant Program has existed for 35 years. Outcomes have improved dramatically as the one-year survival of cadaver kidney grafts increased from 25% to 85-90%. Patient deaths in the first year are now uncommon. Indications for renal transplantation have been extended to infants, the elderly, diabetics and to patients with other significant health problems who would not have been candidates in the past. Chronic administration of large doses of corticosteroids is no longer necessary and the associated morbidity is largely avoided. Improvements in immunosuppression, especially the introduction of cyclosporine, account for much of this progress. With success has come increasing demand. Unfortunately, the gap between the number of available donor kidneys and the number of patients listed for a cadaver transplant continues to increase rather than diminish. Greater acceptance of volunteer donation, as has occurred in our own program, will help to reduce this shortage. If the past forecasts the future, we can anticipate extraordinary advances during the next 35 years.