Contralateral surgery in patients scheduled for total thyroidectomy with initial loss or absence of signal during neural monitoring

BACKGROUND

Staged total thyroidectomy has been advised to prevent bilateral recurrent laryngeal nerve paralysis when loss of the signal from neural monitoring is observed after dissection of the initial thyroid lobe. This is supported by expert opinion but hard evidence is lacking. A lost signal can return during surgery or, even if it persists, its positive predictive value is only in the range 60-70 per cent. The aim of the present study was to investigate the clinical outcome of patients in whom total thyroidectomy was performed following loss of signal after dissection of the first thyroid lobe.

METHODS

This was a prospective observational study of adult patients scheduled for neural monitoring during total thyroidectomy. The prevalence of first-side absence or loss of signal was recorded. The contralateral thyroid lobe was approached routinely. The vagus and recurrent laryngeal nerves on the first side were retested during and at the end of the contralateral procedure.

RESULTS

Some 462 patients were included. Loss (32 patients) or initial absence (8) of signal at dissection of the first thyroid lobe was noted in 40 patients (8·7 per cent). Total thyroidectomy was completed in 29 patients, and a change of surgical strategy adopted in 11 patients with benign disease. At retesting, 15 of 37 initially silent nerves recovered electromyographic signal after a mean(s.d.) interval of 30(14) min. Postoperative vocal cord palsy/paresis was demonstrated in 24 of 40 patients. One patient developed a bilateral paresis that could be managed conservatively.

CONCLUSION

After an absence or loss of signal of the recurrent laryngeal nerve following dissection of the first thyroid lobe, contralateral thyroidectomy can be performed safely, avoiding the expense, psychological burden and potential complications of a second procedure.

An antimicrobial stewardship program reduces antimicrobial therapy duration and hospital stay in surgical wards

We report a quasi-experimental study of the implementation of an antimicrobial stewardship program in two surgical wards, with a pre-intervention period with just assessment of prescription and an intervention period with a prospective audit on antibiotic prescription model. There was a significant reduction of length of stay and the total days of antimicrobial administration. There were no differences in mortality between groups. The antimicrobial stewardship program led to the early detection of inappropriate empirical antibiotic treatment and was associated with a significant reduction in length of stay and the total duration of antimicrobial therapy.

DMSO affects Aβ1–40's conformation and interactions with aggregation inhibitors as revealed by NMR

DMSO alters Abeta's conformation and its recognition by inhibitors.

Abnormal levels of expression of plasma microRNA-33 in patients with psoriasis

INTRODUCTION AND OBJECTIVES

Circulating microRNAs (miRNA) are involved in the posttranscriptional regulation of genes associated with lipid metabolism (miRNA-33) and vascular function and angiogenesis (miRNA-126). The objective of this exploratory study was to measure plasma levels of miRNA-33 and miRNA-126 in patients with plaque psoriasis and evaluate their association with clinical parameters.

MATERIAL AND METHODS

We studied 11 patients with plaque psoriasis. The median Psoriasis Area Severity Index (PASI) was 13 (interquartile range [IQR], 9-14) and body surface area involvement was 12 (IQR, 11-15). Eleven healthy controls matched for age and sex were also included. We analyzed cardiovascular risk factors and subclinical carotid atheromatosis. Plasma miRNAs were evaluated using quantitative real-time polymerase chain reaction.

RESULTS

Carotid intima-media thickness was greater in patients (0.57mm; IQR, 0.54-0.61; n=11) than in controls (0.50mm; IQR, 0.48-0.54; data available for 9 controls) (P=.0055, Mann-Whitney). Expression of miRNA-33 in patients (5.34; IQR, 3.12-7.96; n=11) was significantly higher than in controls (2.33; IQR, 1.71-2.84; only detected in 7 of 11 controls) (P=.0049, Wilcoxon signed rank). No differences in miRNA-126 levels were observed between patients and controls. In patients (n=11), we observed a positive correlation between miRNA-33 and insulin levels (r=0.7289, P=.0109) and a negative correlation between miRNA-126 and carotid intima-media thickness (r=-0.6181, P=.0426).

CONCLUSION

In psoriasis patients plasma levels of lipid and glucose metabolism-related miRNA-33 are increased and correlated with insulin. The study of circulating miRNA-33 in psoriasis may provide new insights about the associated systemic inflammatory abnormalities.

Increased gene expression of Toll-like receptor 4 on peripheral blood mononuclear cells in patients with psoriasis

BACKGROUND

A role for the innate immune system in driving the autoimmune T cell cascade in psoriasis has been proposed. Toll-like receptors-(TLR)-2 and -4 play a role in inflammation, atherosclerosis, and their specific role in psoriasis remains unclear.

OBJECTIVE

To evaluate TLR2 and TLR4 gene expression levels in peripheral blood mononuclear cells from psoriatic patients.

METHODS

Changes in TLR2 ⁄ 4 gene expressions were evaluated using quantitative real-time reverse transcription polymerase chain reaction in peripheral blood mononuclear cells, from twenty-one patients with severe psoriasis, and analysed whether there was any correlation with cytokine plasma levels (T-helper 0-, T-helper 1-, T-helper 2- or regulatory T cells-type), or Calprotectin and with S100A8 and S100A9 gene expression levels. Eleven non-psoriatic healthy controls were analysed.

RESULTS

A clear increase in TLR4 gene expression was observed (3.84 ± 0.93, n = 21) together with a moderate increase in TLR2 expression (1.522 ± 0.31, n = 21). Both TLR4 and TLR2 gene expressions were significantly augmented in psoriatic patients compared with controls (all P < 0.001). Correlations between TLR2 and S100A9 gene expressions (r = 0.5145, P = 0.0170, n = 21); and between TLR2 expression and plasma interleukin-2 (r = 0.5667, P = 0.0074); interleukin-4 (r = 0.4766, P = 0.0289), interleukin-10 (r = 0.4355, P = 0.0484) and interleukin-13 (r = 0.4603, P = 0.0358), were found. When patients with atheroma plaque were considered (n = 7), both TLR4 (3.47 ± 0.99, P = 0.0156) and TLR2 (1.63 ± 0.31, P = 0.0156) expressions were significantly increased vs. controls and correlated with plasma TNF-a (r = 0.8929, P = 0.0123, in both cases).

CONCLUSION

Differential TLR4 ⁄ 2 gene expressions on psoriatic peripheral blood mononuclear cells and correlations with regulatory and ⁄ or proinflammatory cytokines and ⁄ or damage-associated molecular pattern molecule S100A9 emphasize innate immune response role in psoriasis.

Decreased plasma levels of clusterin in patients with psoriasis

INTRODUCTION AND OBJECTIVES

Psoriasis is a chronic inflammatory disease that has been linked to increased cardiovascular risk. The glycoprotein clusterin (apolipoprotein J) is a component of high-density lipoproteins and has a protective role in atherosclerosis. The aim of the present study was to evaluate the plasma levels of clusterin and the proinflammatory cytokine macrophage migration inhibitory factor (MIF) in patients with severe psoriasis, comparing groups of patients with different risks of cardiovascular disease.

MATERIAL AND METHODS

Twenty-one patients with severe psoriasis (psoriasis area severity index and body surface area>10) and 11 healthy controls with no dermatologic disease were studied. Cardiovascular risk factors were assessed according to the Adult Treatment Panel (ATP) III criteria. Subclinical carotid atheromatosis was assessed by Doppler ultrasonography of the carotid arteries. Plasma clusterin and MIF levels were measured by enzyme-linked immunosorbent assay.

RESULTS

ATP-III criteria for metabolic syndrome were met by 47% of the patients, and 33% had carotid atheromatous plaque. Mean (SD) clusterin plasma levels were significantly lower in patients with psoriasis compared with controls (81.39 [27.30] μg/mL for the 21 patients vs 117 [21.6] μg/mL for the 11 controls; P=.0017). MIF plasma levels (ng/ml) were significantly higher in patients with atheromatous plaque compared with controls (53.22 [29.02] for the 6 patients with plaque vs 34.21 [9.65] for the 11 controls; P=.0394).

CONCLUSIONS

The decreased plasma levels of clusterin in psoriatic patients suggested an association with the disease and might be an indicator of systemic inflammatory activity. Increased levels of MIF appear to be associated with cardiovascular risk factors and carotid atheromatous plaque.

Localized and stationary dynamic gratings via stimulated Brillouin scattering with phase modulated pumps

A novel technique for the localization of stimulated Brillouin scattering (SBS) interaction is proposed, analyzed and demonstrated experimentally. The method relies on the phase modulation of two counter-propagating optical waves by a common pseudo-random bit sequence (PRBS), these waves being spectrally detuned by the Brillouin frequency shift. The PRBS symbol duration is much shorter than the acoustic lifetime. The interference between the two modulated waves gives rise to an acoustic grating that is confined to narrow correlation peaks, as short as 1.7 cm. The separation between neighboring peaks, which is governed by the PRBS length, can be made arbitrarily long. The method is demonstrated in the generation and applications of dynamic gratings in polarization maintaining (PM) fibers. Localized and stationary acoustic gratings are induced by two phase modulated pumps that are polarized along one principal axis of the PM fiber, and interrogated by a third, readout wave which is polarized along the orthogonal axis. Using the proposed technique, we demonstrate the variable delay of 1 ns-long readout pulses by as much as 770 ns. Noise due to reflections from residual off-peak gratings and its implications on the potential variable delay of optical communication data are discussed. The method is equally applicable to the modulation of pump and probe waves in SBS over standard fibers.

Tunable and reconfigurable multi-tap microwave photonic filter based on dynamic Brillouin gratings in fibers

We propose and experimentally demonstrate new architectures to realize multi-tap microwave photonic filters, based on the generation of a single or multiple dynamic Brillouin gratings in polarization maintaining fibers. The spectral range and selectivity of the proposed periodic filters is extensively tunable, simply by reconfiguring the positions and the number of dynamic gratings along the fiber respectively. In this paper, we present a complete analysis of three different configurations comprising a microwave photonic filter implementation: a simple notch-type Mach-Zehnder approach with a single movable dynamic grating, a multi-tap performance based on multiple dynamic gratings and finally a stationary grating configuration based on the phase modulation of two counter-propagating optical waves by a common pseudo-random bit sequence (PRBS).

Mechanism of FMN Binding to the Apoflavodoxin from Helicobacter pylori

Flavodoxins are bacterial electron transport proteins whose redox competence is due to the presence of a tightly but noncovalently bound FMN molecule. While the thermodynamics of the complex are understood, the mechanism of association between the apoflavodoxin and the redox cofactor is not so clear. We investigate here the mechanism of FMN binding to the apoflavodoxin from Helicobacter pylori, an essential protein that is being used as a target to develop antimicrobials. This flavodoxin is structurally peculiar as it lacks the typical bulky residue interacting with the FMN re face but bears instead a small alanine. FMN binding is biphasic, regardless of the presence of phosphate molecules in solution, while riboflavin binding takes place in a single step, the rate constant of which coincides with the fast phase of FMN binding. A mutational study at the isoalloxazine and phosphate subsites for FMN binding clearly indicates that FMN association is always limited by interaction with the isoalloxazine subsite because mutating residues that interact with the phosphate moiety of FMN in the native complex hardly changes the observed rate constants and amplitudes. In contrast, replacing tyr92, which interacts with the isoalloxazine, greatly lowers the rate constants. Our analysis indicates that the two FMN binding phases observed are related neither with alternative or sequential interaction with the two binding subsites nor with the presence of bound phosphate. It is possible that they reflect the intrinsic conformational heterogeneity of the apoflavodoxin ensemble.

Specific improvement measures to reduce complications and mortality after urgent surgery in complicated abdominal wall hernia

PURPOSE

Morbidity and mortality are increased after urgent surgery for complicated abdominal wall hernia. We analysed prospectively early morbidity and mortality after implementing specific management measures in patients undergoing urgent hernia repair.

METHODS

The study population included 244 patients with complicated abdominal wall hernia requiring surgical repair on an emergency basis over 1-year period. Patients were managed according to a protocol that included specific actions to be implemented in the pre-, intra- and postoperative periods. Outcomes of these patients were compared with those of 402 undergoing similar operations before development of the protocol.

RESULTS

Patients in whom acute complication was the first hernia symptom had higher mortality (7.2% vs 2.5%; P = 0.07) and were consulted later than 24 h (49.4% vs 36%; P = 0.044). Patients consulting later than 24 h had higher mortality (8.1% vs 1.4%, P = 0.017). Femoral hernias exhibited specific characteristics and were associated with higher mortality (13% vs 1.6%; P = 0.001). Overall, both groups had similar mortality (4.5% vs 4.1%; P = 0.8); complications (38.8% vs 37.7%; P = 0.2), and bowel resection rates (12.2% vs 11.5%; P = 0.8). Excluding the group of femoral hernias, the measures achieved a lower rate of severe complications (21.2% vs 10.3%; P = 0.04) and a decrease in mortality (2.9% vs 0.6%; P = 0.05) after bowel resection.

CONCLUSIONS

Specific measures for improvement of management and prevention of complications and mortality were effective in patients without femoral hernia. To reduce mortality, the best applicable measure is early detection and to prioritize the scheduled operation of femoral hernias and those affecting high risk patients. The implementation of preventive and educational programs in high risk patients is essential.

Computational diagnosis of protein conformational diseases: Short molecular dynamics simulations reveal a fast unfolding of r-LDL mutants that cause familial hypercholesterolemia

The molecular basis of conformational diseases frequently resides in mutant proteins constituting a subset of the vast mutational space. While the subtleties of protein structure point to molecular dynamics (MD) techniques as promising tools for an efficient exploration of such a space, the average size of proteins and the time scale of unfolding events make this goal difficult with present computational capabilities. We show here, nevertheless, that an efficient approach is already feasible for modular proteins. Familial hypercholesterolemia (FH) is a conformational disease linked to mutations in the gene encoding the low density lipoprotein receptor. A high percentage of these mutations has been found in the seven small modular binding repeats of the receptor. Taking advantage of its small size, we have performed an in depth MD study of the fifth binding repeat. Fast unfolding dynamics have been observed in the absence of a structural bound calcium ion, which agrees with its reported essential role in the stability of the module. In addition, several mutations detected in FH patients have been analyzed, starting from the native conformation. Our results indicate that in contrast with the wild type protein and an innocuous control mutant, disease-related mutants experience, in short simulation times (2-8 ns), gross departures from the native state that lead to unfolded conformations and, in some cases, to binding site desorganization deriving in calcium release. Computational diagnosis of mutations leading to conformational diseases seems thus feasible, at least for small or modular pathogenic proteins.

Alpha-helix stabilization by alanine relative to glycine: roles of polar and apolar solvent exposures and of backbone entropy

The energetics of alpha-helix formation are fairly well understood and the helix content of a given amino acid sequence can be calculated with reasonable accuracy from helix-coil transition theories that assign to the different residues specific effects on helix stability. In internal helical positions, alanine is regarded as the most stabilizing residue, whereas glycine, after proline, is the more destabilizing. The difference in stabilization afforded by alanine and glycine has been explained by invoking various physical reasons, including the hydrophobic effect and the entropy of folding. Herein, the contribution of these two effects and that of hydrophilic area burial is evaluated by analyzing Ala and Gly mutants implemented in three helices of apoflavodoxin. These data, combined with available data for similar mutations in other proteins (22 Ala/Gly mutations in alpha-helices have been considered), allow estimation of the difference in backbone entropy between alanine and glycine and evaluation of its contribution and that of apolar and polar area burial to the helical stabilization typically associated to Gly-->Ala substitutions. Alanine consistently stabilizes the helical conformation relative to glycine because it buries more apolar area upon folding and because its backbone entropy is lower. However, the relative contribution of polar area burial (which is shown to be destabilizing) and of backbone entropy critically depends on the approximation used to model the structure of the denatured state. In this respect, the excised-peptide model of the unfolded state, proposed by Creamer and coworkers (1995), predicts a major contribution of polar area burial, which is in good agreement with recent quantitations of the relative enthalpic contribution of Ala and Gly residues to alpha-helix formation.

[Evolution of severe pain associated to spontaneous spinal epidural hematoma]

INTRODUCTION

Spontaneous spinal epidural hematoma is an infrequent disease, whose clinical presentation is very characteristic, with severe pain in region corresponding to the metameres affected, which orients its diagnosis and early treatment.

CLINICAL CASES

Three clinical cases that occurred during 2003 and 2004 are presented. All three were middle- aged men, with spondyloarthrosis signs, posterolateral cervical location of hematoma, which debuted with severe cervical and cervicobrachial pain. This was followed by acute onset motor and sensory paralysis with spontaneous complete recovery in hours, only the pain persisting. The three patients were treated conservatively, pain being the main symptom. This pain only responded to intravenous steroids.

CONCLUSIONS

The evolution of the pain and pathophysiological mechanism by which the corticoids could improve the pain associated to these diseases are discussed.

Native-specific stabilization of flavodoxin by the FMN cofactor: structural and thermodynamical explanation

Flavodoxins are useful models to investigate protein/cofactor interactions. The binding energy of the apoflavodoxin-FMN complex is high and therefore the holoflavodoxin is expected to be more stable than the apoprotein. This expectation has been challenged by reports on the stability of Desulfovibrio desulfuricans flavodoxin indicating that FMN binds to the unfolded polypeptide with similar affinity as to the native state, thus causing no net effect on protein stability. In previous work, we have analyzed in detail the stability of the apoflavodoxin from Anabaena PCC 7119 and the energetics of its functional complex with FMN. Here, we use the Anabaena holoprotein to directly investigate the contribution of the bound cofactor to protein stability through a detailed analysis of the chemical and thermal denaturation equilibria. Our data clearly shows that FMN binding largely stabilizes the protein towards both chemical and thermal denaturation, and that the stabilization observed at 25 degrees C in low ionic strength conditions is precisely the one expected if full release of the cofactor takes place upon flavodoxin unfolding. On the other hand, the binding of FMN to the native polypeptide is shown to simplify the thermal unfolding so that, while apoflavodoxin follows a three-state mechanism, the holoprotein unfolds in a two-state fashion. Comparison of the X-ray structure of native apoflavodoxin with the phi-structure of the thermal intermediate indicates that the increase in cooperativity driven by the cofactor originates in its preferential binding to the native state, which is a consequence of the disorganization in the intermediate of the FMN binding loops and of an adjacent longer loop.

Flavodoxins: sequence, folding, binding, function and beyond

Flavodoxins are electron-transfer proteins involved in a variety of photosynthetic and non-photosynthetic reactions in bacteria, whereas, in eukaryotes, a descendant of the flavodoxin gene helps build multidomain proteins. The redox activity of flavodoxin derives from its bound flavin mononucleotide cofactor (FMN), whose intrinsic properties are profoundly modified by the host apoprotein. This review covers the very exciting last decade of flavodoxin research, in which the folding pathway, the structure and stability of the apoprotein, the mechanism of FMN recognition, the interactions that stabilize the functional complex and tailor the redox potentials, and many details of the binding and electron transfer to partner proteins have been revealed. The next decade should witness an even deeper understanding of the flavodoxin molecule and a greater comprehension of its many physiological roles. The fact that flavodoxin is essential for the survival of some human pathogens could make it a drug target on its own.

Equilibrium Φ-Analysis of a Molten Globule: The 1-149 Apoflavodoxin Fragment

The apoflavodoxin fragment comprising residues 1-149 that can be obtained by chemical cleavage of the C-terminal alpha-helix of the full-length protein is known to populate a molten globule conformation that displays a cooperative behaviour and experiences two-state urea and thermal denaturation. Here, we have used a recombinant form of this fragment to investigate molten globule energetics and to derive structural information by equilibrium Phi-analysis. We have characterized 15 mutant fragments designed to probe the persistence of native interactions in the molten globule and compared their conformational stability to that of the equivalent full-length apoflavodoxin mutants. According to our data, most of the mutations analysed modify the stability of the molten globule fragment following the trend observed when the same mutations are implemented in the full-length protein. However, the changes in stability observed in the molten globule are much smaller and the Phi-values calculated are (with a single exception) below 0.4. This is consistent with an overall and significant debilitation of the native structure. Nevertheless, the fact that the molten globule fragment can be stabilised using as a guide the native structure of the full-length protein (by increasing helix propensity, optimising charge interactions and filling small cavities) suggests that the overall structure of the molten globule is still quite close to native, in spite of the lowered stability observed.

[Respiratory muscle aids during an episode of aspiration in a patient with Duchenne muscular dystrophy]

We report the case of a Duchenne muscular dystrophy patient with good bulbar function but severely decreased forced vital capacity (9%) and spontaneous peak cough flow (PCF) (2.35 L/s). The patient needed continuous noninvasive ventilation (NIV) consisting of a volumetric ventilator with a nighttime nasal mask and a daytime mouthpiece. He also required application of manually assisted coughing techniques by insufflation with a resuscitation bag and chest thrust (manually assisted PCF after maximum insufflation capacity of 4.33 L/s). An episode of serious food aspiration was resolved by his main caregiver through NIV and manually assisted coughing. Bronchoscopy under sedation using NIV with a lip seal connection to his volumetric ventilator later revealed that no material remained. This case exemplifies the potential role of skilled respiratory management in some neuromuscular diseases.

[Quality of the health care to the epileptic patients in Spain]

INTRODUCTION

The objective of the study was to evaluate the quality of the health care to the epileptic patient in Spain including recently diagnosed patients, controlled patients and medically refractory patients.

METHODS

Throughout years 2001-2002 a questionnaire of consensus was agreed by neurologists from surgical epilepsy units, epilepsy units, community hospitals and outpatient clinics.

RESULTS

A total of 139 questionnaires were analysed. Only one third of the hospitals had a specialized epilepsy clinic. The longest waiting lists for diagnostic procedures were video EEG and Holter EEG, with 175 and 97.6 days, respectively. Clear differences between autonomous communities as far as availability of neurologists on duty, availability of diagnostic tests and number of epilepsy units are stated, existing, in general, more resources in the autonomous communities with health transferred before 2002 and Madrid.

CONCLUSIONS

As much the lack of resources as the inequalities indicate that we are still far from the quality standards recommended by the International League Against Epilepsy (ILAE), lacking a suitable lanning that eliminates the inequalities and it so approaches us a system of assistance integrated in different levels as it is set out by the international scientific community.