Development and evaluation of a novel pre-operative surgery school and behavioural change intervention for patients undergoing elective major surgery: Fit-4-Surgery School

Group pre-operative education has usually been limited to conditioning expectations and providing education. Prehabilitation has highlighted modifiable lifestyle factors that are amenable to change and may improve clinical outcomes. We instituted a pre-operative 'Fit-4-Surgery School' for patients scheduled for major surgery, to educate and promote healthy behaviour. We evaluated patients' views having attended the school, and after surgery we asked how it had changed their behaviour with a lifestyle questionnaire. The school was launched in May 2016 and was attended by 586/1017 (58%) of invited patients. Patients who did not attend: lived further away, median (IQR [range]) 8 (4-19 [0-123]) miles vs. 5 (3-14 [0-172]) miles, p < 0.001; and were more deprived, Index of Multiple Deprivation Rank decile median (IQR [range]), 6 (4-8 [1-10]) vs. 7 (4-9 [1-10]), p = 0.04. Of the 492/586 (84%) participants who completed an evaluation questionnaire, 462 (94%) would recommend the school to a friend having surgery and 296 (60%) planned lifestyle changes. After surgery, 232/586 (40%) completed a behavioural change questionnaire, 106 (46%) of whom reported changing at least one lifestyle factor, most commonly by increasing exercise. The pre-operative school was acceptable to patients.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Factors associated with first thrombosis in patients presenting with obstetric antiphospholipid syndrome (APS) in the APS Alliance for Clinical Trials and International Networking Clinical Database and Repository: a retrospective study

OBJECTIVE

To evaluate the subsequent rate of thrombosis among women with obstetric antiphospholipid syndrome (Ob-APS) in a multicentre database of antiphospholipid antibody (aPL)-positive patients, and the clinical utility of the adjusted Global Antiphospholipid Syndrome Score (aGAPSS), a validated tool to assess the likelihood of developing new thrombosis, in this group of patients.

DESIGN

Retrospective study.

SETTING

The Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking Clinical Database and Repository.

POPULATION

Women with Ob-APS.

METHODS

Comparison of clinical and laboratory characteristics and measurement of aGAPSS in women with Ob-APS, with or without thrombosis, after initial pregnancy morbidity (PM).

MAIN OUTCOME MEASURES

Risk factors for thrombosis and aGAPSS.

RESULTS

Of 550 patients, 126 had Ob-APS; 74/126 (59%) presented with thrombosis, and 47 (63%) of these women developed thrombosis after initial PM, in a mean time of 7.6 ± 8.2 years (4.9/100 patient years). Younger age at diagnosis of Ob-APS, additional cardiovascular risk factors, superficial vein thrombosis, heart valve disease, and multiple aPL positivity increased the risk of first thrombosis after PM. Women with thrombosis after PM had a higher aGAPSS compared with women with Ob-APS alone [median 11.5 (4-16) versus 9 (4-13); P = 0.0089].

CONCLUSION

Based on a retrospective analysis of our multicentre aPL database, 63% of women with Ob-APS developed thrombosis after initial obstetric morbidity; additional thrombosis risk factors, selected clinical manifestations, and high-risk aPL profile increased the risk. Women with subsequent thrombosis after Ob-APS had a higher aGAPSS at entry to the registry. We believe that aGAPSS is a valid tool to improve risk stratification in aPL-positive women.

TWEETABLE ABSTRACT

More than 60% of women with obstetric antiphospholipid syndrome had thrombosis after initial pregnancy morbidity.

Bilateral versus unilateral botulinum toxin injections for chronic anal fissure: a randomised trial

BACKGROUND

Botulinum toxin injected into the internal anal sphincter is used in the treatment of chronic anal fissure but there is no standardised technique for its administration. This randomised single centre trial compares bilateral (either side of fissure) to unilateral injection.

METHODS

Participants were randomised to receive bilateral (50 + 50 units) or unilateral (100 units) Dysport® injections into the internal anal sphincter in an outpatient setting. Injection-related pain assessed by visual analogue scale was the primary outcome measure. Secondary outcomes were healing rate, fissure pain, incontinence, and global health scores.

RESULTS

Between October 2008 and April 2012, 100 patients with chronic anal fissure were randomised to receive bilateral or unilateral injections. Injection-related pain was comparable in both groups. There was no difference in healing rate. Initially, there was greater improvement in fissure pain in the bilateral group but at 1 year the unilateral group showed greater improvement. Cleveland Clinic Incontinence score was lower in the unilateral group in the early post-treatment period and global health assessment (EuroQol EQ-VAS) was higher in the unilateral group at 1 year.

CONCLUSIONS

Injection-related pain was similar in bilateral and unilateral injection groups. Unilateral injection was as effective as bilateral injections in healing and improving fissure pain without any deterioration in continence.

Molecular and biochemical characterisation and recognition by the immune host of the glyceraldehyde 3-phosphate dehydrogenase (GAPDH) of the abomasal nematode parasite Teladorsagia circumcincta

A 1023 bp full length cDNA encoding Teladorsagia circumcincta GAPDH (TeciGAPDH) was cloned, expressed in Escherichia coli and the recombinant protein purified and its kinetic properties determined. A phylogenetic tree was constructed using helminth GAPDH sequences. The predicted protein consisted of 341 amino acids and was present as a single band of about 38 kDa on SDS-PAGE. Multiple alignments of the protein sequence of TeciGAPDH with homologues from other helminths showed that the greatest similarity (93%) to the GAPDH of Haemonchus contortus and Dictyocaulus viviparus, 82-86% similarity to the other nematode sequences and 68-71% similarity to cestode and trematode enzymes. Substrate binding sites and conserved regions were identified and were completely conserved in other homologues. At 25 °C, the optimum pH for TeciGAPDH activity was pH 8, the V_max was 1052 ± 23 nmol min^-1 mg^-1 protein and the apparent K_m for the substrate glyceraldehyde-3-phosphate was 0.02 ± 0.01 mM (both mean ± SD, n = 2). Antibodies in both serum and saliva from field-immune, but not nematode-naïve, sheep recognised recombinant TeciGAPDH in enzyme-linked immunosorbent assays. The recognition of the recombinant protein by antibodies generated by exposure of sheep to native GAPDH indicates similar antigenicity of the two proteins.

Hydroxychloroquine in the primary thrombosis prophylaxis of antiphospholipid antibody positive patients without systemic autoimmune disease

Objective The objective of this study was to determine the efficacy of hydroxychloroquine (HCQ) in the primary thrombosis prevention of antiphospholipid antibody (aPL)-positive patients with no other systemic autoimmune diseases. Methods Under the auspices of Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking, a multicenter, international, randomized controlled trial (RCT) was initiated, in which persistently aPL-positive but thrombosis-free patients without systemic autoimmune diseases were randomized to receive HCQ or no treatment in addition to their standard regimen. The primary objective was the efficacy of HCQ in preventing the first thrombosis. The secondary objectives were the thrombosis incidence rate, and the effects of HCQ on aPL profile and mortality rate. Patients were risk-stratified based on antiplatelet agent use. The goal was to follow patients every 6 months for 5 years. Results We recruited 20 persistently aPL-positive patients (female: 19, mean age: 46.6 ± 9.9 years, and baseline antiplatelet medication: 14); 9/20 were randomized to HCQ. During the mean follow-up of 1.7 years, no patients developed thrombosis or a serious adverse event. The study was terminated early due to the low recruitment rate, exacerbated by the prolonged manufacturing shortage and significant price increase of HCQ in the United States. Conclusion Given that a small number of patients with a relatively short follow-up were enrolled in our RCT, and no patients developed thrombosis, we cannot accurately assess the effectiveness of HCQ for primary thrombosis prevention in persistently aPL-positive patients with no other systemic autoimmune diseases. Our experience suggests that conducting an international RCT, especially without pharmaceutical support, is an extremely challenging undertaking.

Molecular and biochemical characterisation and recognition by the immune host of the enolase of the abomasal nematode parasite Teladorsagia circumcincta

A 1299 bp full length cDNA encoding Teladorsagia circumcincta enolase (TeciENO) was cloned, expressed in Escherichia coli and the recombinant protein purified and its kinetic properties determined. Helminth enolase sequences were used to construct a phylogenetic tree. The predicted protein consisted of 433 amino acids and was present as a single band of about 50 kDa on SDS-PAGE. Multiple alignments of the protein sequence of TeciENO with homologues from other helminths showed 98% similarity with Haemonchus contortus enolase, 78-95% similarity to other nematode sequences and 72-75% similarity to cestode and trematode enolases. Substrate binding sites and conserved regions were identified and were completely conserved in other homologues. The optimum pH for TeciENO activity at 25 °C was pH 7, the K_m for 2-phophoglycerate 0.09 ± 0.04 mM and the V_max was 604 ± 6 nmol min^-1 mg^-1 protein (both mean ± SD, n = 2). TeciENO activity was inhibited by 11.5% by 1 mM citrate (p < 0.001). Antibodies in both serum and saliva from field-immune, but not nematode-naïve, sheep recognised recombinant TeciENO in enzyme-linked immunosorbent assays. The recognition of the recombinant protein by antibodies generated by exposure of sheep to native enolase indicates similar antigenicity of the two proteins.

Immunomodulatory effects of adult Haemonchus contortus excretory/secretory products on human monocyte-derived dendritic cells

The levels of expression of surface molecules and release of cytokines and chemokines of human monocyte-derived dendritic cells were determined after their exposure to adult H. contortus excretory/secretory (ES) products or a combination of ES products and bacterial lipopolysaccharide (LPS). Worm products provoked a weak response and only partial maturation of the dendritic cells, consistent with the hyporesponsiveness and more tolerogenic immune environment present in parasitized animals and humans. Co-stimulation with LPS demonstrated that H. contortus secretions, like those of other helminths, contain immunomodulators capable of reducing some aspects of the strong T(H)1/T(H)2 response evoked by bacterial LPS. There were significant reductions in the release of some cytokine/chemokines by LPS-stimulated mdDCs and a trend (although not significant at P < 0.05) for reduced expression levels of CD40, CD80 and HLA-DR. A prominent feature was the variability in responses of dendritic cells from the four donors, even on different days in repeat experiments, suggesting that generalized conclusions may be difficult to make, except in genetically related animals. Such observations may therefore be applicable only to restricted populations. In addition, previous exposure to parasites in a target population for immunomodulatory therapy may be an important factor in assessing the likelihood of adverse reactions or failures in the treatment to worm therapy.

Activation-induced cytidine deaminase (AID) is strongly expressed in the fetal bovine ileal Peyer's patch and spleen and is associated with expansion of the primary antibody repertoire in the absence of exogenous antigens

Due to a limited range of immunoglobulin (Ig) genes, cattle and several other domestic animals rely on postrecombinatorial amplification of the primary repertoire. We report that activation-induced cytidine deaminase (AID) is strongly expressed in the fetal bovine ileal Peyer's patch and spleen but not in fetal bone marrow. The numbers of IGHV (immunoglobulin heavy chain variable) mutations correlate with AID expression. The mutational profile in the fetuses is similar to postnatal and immunized calves, with targeting of complementarity-determining region (CDR) over framework region (FR), preference of replacement over silent mutations in CDRs but not in FRs, and targeting of the AID hotspot motif RGYW/WRCY. Statistical analysis indicates negative selection on FRs and positive selection on CDRs. Our results suggest that AID-mediated somatic hypermutation and selection take place in bovine fetuses, implying a role for AID in the diversification of the primary antibody repertoire in the absence of exogenous antigens.

Molecular and biochemical characterisation of arginine kinases in Haemonchus contortus and Teladorsagia circumcincta

Full length cDNA encoding arginine kinases (AK) were cloned from Teladorsagia circumcincta (TcAK) and Haemonchus contortus (HcAK). The TcAK and HcAK cDNA (1080 bp) encoded 360 amino acid proteins. The predicted amino acid sequence showed 99% similarity with each other and 94% with a Caenorhabditis elegans AK. Soluble N-terminal His-tagged AK proteins were expressed in Escherichia coli strain BL21, purified and characterised. All binding sites were completely conserved in both proteins. The recombinant TcAK and HcAK had very similar kinetic properties: K(m) arginine was 0.35 mM, K(m) ATP was 0.8-0.9 mM and the pH optima were pH 7.5. Arginine analogues strongly inhibited recombinant enzyme activities (up to 80%), whilst other amino acids decreased activities by a maximum of 20%. TcAK and HcAK are potential vaccine candidates because of the strong antigenicity of invertebrate phosphagens and kinases and presence in metabolically active parts of the worm.

Early experience with laparoscopic extralevator abdominoperineal excision within an enhanced recovery setting: analysis of short-term outcomes and quality of life

INTRODUCTION

Conventional abdominoperineal excision for low rectal cancer has a higher local recurrence and reduced survival compared to anterior resection. An extralevator abdominoperineal excision (ELAPE) may improve outcome through removal of increased tissue in the distal rectum. Experience with ELAPE is limited and no studies have reported on quality of life (QOL) following this procedure. We describe a minimally invasive approach to ELAPE within an enhanced recovery programme, and present short-term results and QOL analyses.

METHODS

All laparoscopic ELAPEs were included in a prospective database. Demographics, intra-operative and post-operative outcomes were evaluated. Postoperative QOL was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires QLQ-C30 and QLQ-CR29.

RESULTS

Thirteen laparoscopic ELAPEs were performed over a two-year period. All were enrolled in an enhanced recovery programme. The median age was 76. The median tumour height was 20 mm (range: 0-50 mm) from the dentate line and all patients received neoadjuvant treatment. The median duration of surgery was 300 minutes (range: 120-488 minutes), the mean blood loss was 150 ml and one procedure was converted to open surgery. There was no circumferential resection margin involvement or tumour perforation. The median duration of use of intravenous fluid, patient controlled analgesia and urinary catheterisation was 2, 2 and 2.5 days respectively and the median length of hospital stay was 7.5 days. Two patients developed perineal wound dehiscence. QOL analysis revealed high global health status (90.8), physical (91.3), emotional (98.3) and social functioning (100) scores, which compared favourably with EORTC reference values and published QOL scores following conventional abdominoperineal excision.

CONCLUSIONS

Laparoscopic ELAPE within an enhanced recovery setting is a feasible and safe approach with acceptable short-term outcomes and post-operative quality of life.

Molecular and biochemical characterisation of a Teladorsagia circumcincta glutamate dehydrogenase

A full length cDNA encoding glutamate dehydrogenase was cloned from Teladorsagia circumcincta (TcGDH). The TcGDH cDNA (1614 bp) encoded a 538 amino acid protein. The predicted amino acid sequence showed 96% and 93% similarity with Haemonchus contortus and Caenorhabditis elegans GDH, respectively. A soluble N-terminal 6xHis-tagged GDH protein was expressed in the recombinant Escherichia coli strain BL21 (DE3) pGroESL, purified and characterised. The recombinant TcGDH had similar kinetic properties to those of the enzyme in homogenates of T. circumcincta, including greater activity in the aminating than deaminating reaction. Addition of 1mM ADP and ATP increased activity about 3-fold in the deaminating reaction, but had no effect in the reverse direction. TcGDH was a dual co-factor enzyme that operated both with NAD(+) and NADP(+), GDH activity was greater in the deaminating reaction with NADP(+) as co-factor and more with NADH in the aminating reaction.

National UK audit of procedure for prolapsing haemorrhoids on behalf of the Association of Coloproctology of Great Britain and Ireland

OBJECTIVE

To assess the safety and short term outcomes of the procedure for prolapsing haemorrhoids (PPH), a relatively new procedure for the treatment of symptomatic haemorrhoids.

METHOD

In 2005, the Association of Coloproctology of Great Britain and Ireland set up an online electronic database to audit the indications and outcomes for patients undergoing a PPH procedure.

RESULTS

During the audit period, 695 patients were entered onto the database by 61 surgeons (range 1-50 patients per surgeon). The main indications for surgery were bleeding (90.5%) and prolapse (83.9%). Three hundred and ninety-seven (57.1%) patients had grade III or IV haemorrhoids. PPH was performed under general anaesthetic in 602 (86.6%) cases and a consultant surgeon performed the procedure in 572 (82.3%) cases. The median length of stay was 1 day (range 0-6 days). Two hundred and eighty-nine (41.6%) procedures were performed as a day case. Immediate complications were recorded in 75 (10.8%) patients, the commonest being bleeding (21) and urinary retention (24). At 6-week follow-up, 626 (90.1%) patients were pain free. Five patients required hospital re-admission for secondary haemorrhage (3), peri-anal abscess (1) and pain (1). The commonest problems were minor bleeding (48), urgency (22), pain (14), continued prolapse (12) and pruritus (11). Four patients required an open haemorrhoidectomy for persistent symptomatic haemorrhoids.

CONCLUSION

Procedure for PPH is a safe and effective procedure for symptomatic haemorrhoids with good short-term outcomes. Long-term follow-up is required perhaps through a compulsory national register.

A double-blind randomised trial to evaluate the effect of anastrozole for the treatment of non-toxic multinodular goitre

Multinodular goitre (MNG) is a common clinical finding, particularly in females and is usually asymptomatic. When symptoms occur because of local pressure-related effects the only treatment is surgical involving partial or total thyroidectomy. A number of epidemiological observations and experimental data have suggested that oestrogen aromatase activity may be involved in the pathogenesis of MNG. This study examines the effect of anastrozole, a non-steroidal aromatase inhibitor that inhibits the peripheral conversion of testosterone to oestradiol, in reducing the size of MNG. Thirty-two post-menopausal female patients, median age 63 years (range 42-84) were randomised in a double-blind fashion to receive either anastrozole 1 mg daily or placebo for 3 months. Ultrasonographic measurement of each thyroid lobe and isthmus together with complete biochemical and hormone profiles were performed at the start and end of treatment. There was no significant reduction in the goitre size for patients in the anastrozole group (p = 0.246) or the placebo group (p = 0.418). There were no significant changes in hormone profiles (including throglobulin concentration) within each group between the start and end of the study. We conclude that the use of anastrozole in the treatment of MNG does not appear to have any effect in reducing the size of MNG.

Multi Centre Study to Assess the Feasibility of a New Covered Stent and Delivery System in Combination with Remote Superficial Femoral Artery Endarterectomy (RSFAE)

OBJECTIVES

To evaluate the feasibility and efficacy of an innovative new covered stent and adjustable deployment system (aSpire Covered Stent, Vascular Architects Inc., San Jose, CA, USA) in combination with remote superficial femoral artery endarterectomy (RSFAE) for the treatment of long segment femoropopliteal occlusive disease.

DESIGN

Prospective multi-centre trial.

MATERIALS AND METHODS

Sixty-two limbs in 61 patients (41 men; median age 69 years, range 40-88) with severe disabling claudication (n=56) or critical limb ischaemia (n=6) were treated in five European centres with aSpire stenting after RSFAE for long segment occlusions (mean length 25 cm). Follow-up was by duplex scanning at 1-, 6-, 12- and 18-months. Primary, primary-assisted and secondary patency rates were analysed.

RESULTS

The median follow-up was 17 (range 2-34) months. A mean of 1.3 stents (range 1-3) were deployed with a median stent diameter of 7 mm (range 6-9). There were one early and 24 late failures. At 18-months the cumulative primary, primary-assisted and secondary patency rates were 60, 70 and 72%, respectively. There were no device related adverse events, such as kinking or fracturing and no stent migrations.

CONCLUSIONS

The aSpire stent and the delivery system are both safe and feasible in combination with RSFAE. The mid term follow-up appears favourable in view of the long segment occlusions treated. Further follow-up is required to compare the mid- and long-term outcomes with current stents and conventional femoropopliteal bypass.

Acute Abdominal Pain for the General Physician - who, when and how to refer to the on-call surgeon

Patients with abdominal pain are most frequently referred to the on-call surgical team, but there are occasions when physicians may be required to assess, investigate or treat such patients. This article aims to equip non-surgeons with the skills to undertake an appropriate initial assessment and consider the most appropriate selection, timing and mode of referral to the surgical team.

Timing of urgent laparoscopic cholecystectomy does not influence conversion rate

BACKGROUND

The optimal treatment of acute gallstone disease is urgent laparoscopic cholecystectomy, but there is confusion about the effect of delay in operation on conversion rates. Most reports suggest that delay beyond 3 or 4 days leads to a higher conversion rate. This study assessed the conversion rate in relation to the timing of laparoscopic surgery.

METHODS

This institution operates a specialist-led protocol for the urgent management of all admissions with acute gallstone disease. Data were collected prospectively over 6 months.

RESULTS

Between March and August 2002, 84 patients with acute gallstone disease underwent urgent laparoscopic cholecystectomy at the index admission with an overall conversion rate of 12 per cent. Four of 40 procedures carried out within 3 days of admission were converted, compared with six of 44 after 3 days. Five of 46 carried out within 4 days of admission were converted, compared with five of 38 after 4 days. There were no deaths and one common bile duct injury.

CONCLUSION

As long as the procedure is carried out by experienced upper gastrointestinal surgeons working within a specialist-led protocol, the conversion rate for laparoscopic cholecystectomy can be as low as 12 per cent. The timing of urgent laparoscopic cholecystectomy has no impact on the conversion rate.

Implementation of a specialist-led service for the management of acute gallstone disease

Background

The ‘gold standard’ treatment for acute cholecystitis and biliary colic requiring hospital admission is urgent laparoscopic cholecystectomy. This is not routinely available in all hospitals.

Methods

A retrospective audit of emergency admissions with acute cholecystitis or biliary colic from January to December 2000 led to the development and implementation of a specialist-led protocol for the urgent management of acute gallstone disease. A second audit was carried out covering the 6 months after implementation.

Results

One hundred and fifty-eight patients were admitted with acute cholecystitis or biliary colic in the first audit period and 110 in the second interval. The rate of cholecystectomy at index admission increased from 37·3 to 67·3 per cent, at a median of 3 days after admission, and the conversion rate to open surgery fell from 32 to 12 per cent. Median hospital stay fell from 9 to 5·5 days, and the unplanned readmission rate decreased from 19·0 to 3·6 per cent.

Conclusion

Urgent cholecystectomy for the management of acute gallstone disease is feasible and achievable in an acute services hospital with a specialist upper gastrointestinal team. It can lead to a reduced conversion rate, shorter hospital stay, fewer unplanned readmissions, an acceptable operating time and a low complication rate. The protocol is recommended for implementation in other hospitals.

Technique for fabricating a prosthetic tooth on a removable partial denture framework

When removable partial dentures are fabricated, a custom-made tooth may be needed to fill a space too small or irregularly shaped to allow the use of a prefabricated prosthetic tooth. This article describes a simple technique in which visible light-polymerized composite is used to custom build a prosthetic tooth that is both esthetic and durable.

Simple technique to fabricate provisional restorations for porcelain veneers

Fabrication of provisional restorations for teeth prepared to receive porcelain veneers can be a time-consuming and difficult task. This article describes a simple, quick, and predictable procedure to make these restorations. A clinical case is presented to illustrate the technique.

Phenotypic characterization of a comprehensive set of bicyclomycin-resistant mutants

A comprehensive set of bicyclomycin-resistant mutants of transcription termination protein Rho has been characterized in Escherichia coli by in vivo and in vitro assays. Several of the mutant Rho proteins have functional defects. Strains with either the L208R or the S266A mutation in the bacterial chromosome have a higher intracellular concentration of the Rho protein than strains containing a wild-type copy of the rho gene. Strains carrying the L187R, L208R or S266A mutations in the chromosome also have a mutant phenotype; a plasmid-located arabinose promoter is constitutively de-repressed in these strains. The L208R and S266A mutant strains also have a rate of growth defect. When the S266A mutation is located on a high-copy plasmid, the mutant grows more slowly than a wild-type strain. In contrast to the majority of the bicyclomycin-resistant mutants, these two mutants show clear phenotypic differences from wild-type cells. These differences are also seen in vitro. In vitro transcription termination by RhoL208R and RhoS266A is defective at the lambda tR1 terminator, but can be enhanced by NusG. These functionally defective Rho mutations have been located near the putative catalytic site on a model of Rho based on the F1-ATPase. This indicates that this region of the Rho molecule is crucial for Rho function. The crucial region overlaps the putative bicyclomycin-binding site, suggesting an explanation for the efficacy of bicyclomycin as an antibiotic.

Structural isomers of C2N+: a selected-ion flow tube study

Reactivities of the structural isomers CCN+ and CNC+ were examined in a selected-ion flow tube at 300 +/- 5 K. The less reactive CNC+ isomer was identified as the product of the reactions of C(+) + HCN and C(+) + C2N2; in these reactions only CNC+ can be produced because of energy constraints. Rate coefficients and branching ratios are reported for the reactions of each isomer with H2, CH4, NH3, H2O, C2H2, HCN, N2, O2, N2O, and CO2. Ab initio calculations are presented for CCN+ and CNC+; a saddle point for the reaction CCN+ --> CNC+ is calculated to be 195 kJ mol-1 above the CNC+. The results provide evidence that the more reactive CCN+ isomer is unlikely to be present in measurable densities in interstellar clouds.

The latency-associated nuclear antigen of Kaposi's sarcoma-associated herpesvirus transactivates the telomerase reverse transcriptase promoter

Telomerase is a multi-subunit ribonucleoprotein holoenzyme that stabilizes telomere length through the addition of new repeat sequence to the ends of chromosomes. Telomerase reverse transcriptase is the subunit of this complex responsible for the enzymatic activity of telomerase. Expression of the reverse transcriptase is regulated at the level of transcription through the action of transcription factors that target its promoter. Most Kaposi's sarcoma tumor cells are latently infected with the Kaposi's sarcoma-associated herpesvirus, and the constitutive expression of a viral-encoded latency-associated nuclear antigen has been shown to be important for the maintenance of the viral episome. The proliferative nature of Kaposi's sarcoma suggests that this antigen may also play a critical role in viral-mediated oncogenesis. In this study telomerase reverse transcriptase promoter elements cloned into a luciferase reporter plasmid were analyzed to determine the ability of the latency-associated nuclear antigen to regulate transcription. The latency-associated nuclear antigen transactivated the full-length promoter in 293T, 293, and BJAB cell lines. Furthermore, truncation promoter studies implicated sequence from -130 to +5 in viral-mediated activation. This region contains five Sp1 transcription factor-binding sites. Electrophoretic mobility shift assays indicated that the latency-associated nuclear antigen targets and affects the Sp1-DNA complex in the context of BJAB nuclear extracts.

Restoration of extensive erosion areas using an indirect composite technique

Cervical erosion defects, particularly those of extensive size that are located in an area where control of the operative field is difficult, can present a significant restorative challenge. This article describes an indirect restorative technique to solve this problem. Following tooth preparation, an indirect restoration is luted to the tooth and the margins are finished and polished. Using an indirect technique minimizes operative field isolation time and the total chairside time required to restore the tooth. Clinical cases are presented to illustrate this technique.

The effect of a dental unit waterline treatment regimen on the shear bond strength of resin-based composite

BACKGROUND

Numerous methods of disinfecting dental waterlines have been suggested. This study evaluates the effects of one disinfecting technique on the strength of resin-based composite's bond to enamel and to dentin.

METHODS

The authors bonded resin-based composite cylinders to enamel and dentin surfaces similarly mounted and prepared using three irrigation solutions. After undergoing acid etching, the tooth surface was rinsed with either distilled water, water from a municipal water source or a mixture of distilled water and mouthwash concentrate. The authors shear-tested the samples and analyzed the data statistically.

RESULTS

The group rinsed with distilled water mixed with mouthwash exhibited the lowest shear bond strengths. However, a one-way ANOVA indicated no statistically significant differences in the mean values among the treatment groups for either enamel (P = .295) or dentin (P = .393). Specimens bonded to enamel demonstrated primarily adhesive fracture at the tooth/composite interface. Those bonded to dentin showed a similar pattern, with some sites of cohesive fracture in the resin-based composite.

CONCLUSIONS

There was no significant difference in shear bond strengths of resin-based composite to tooth structure when rinsed with distilled water mixed with mouthwash, distilled water or water from a municipal source.

CLINICAL IMPLICATIONS

Dental unit waterlines disinfected using a diluted mouthwash solution may be used while bonding resin-based composite to either enamel or dentin.

Topical diltiazem ointment in the treatment of chronic anal fissure

BACKGROUND

Chronic anal fissure has traditionally been treated surgically. Initial enthusiasm for chemical sphincterotomy has waned because of poor outcomes with glyceryl trinitrate ointment. In this study the use of topical 2 per cent diltiazem ointment has been investigated as an alternative method of chemical sphincterotomy.

METHODS

A prospective assessment of 71 consecutive patients with a chronic anal fissure treated with 2 per cent topical diltiazem ointment for a median duration of 9 (range 2--16) weeks was performed.

RESULTS

Fifty-one patients (75 per cent) experienced healing of the fissure after 2--3 months of treatment with topical diltiazem. Seventeen patients who did not heal were treated for a further 8 weeks with topical diltiazem. Eight of these patients subsequently healed with diltiazem. Fifty-nine of 67 patients who completed follow-up therefore healed on diltiazem ointment. Four patients experienced perianal dermatitis and one patient experienced headaches. No other side-effects were recorded. After a median of 32 (range 14--67) weeks' follow-up following completion of treatment, 27 of 41 patients available remain symptom free. Six of seven patients with recurrent fissure were treated successfully by repeat chemical sphincterotomy.

CONCLUSION

Topical 2 per cent diltiazem ointment used as an agent for chemical sphincterotomy for chronic anal fissure offers significant healing rates but does not have a significant side-effect profile, which may aid compliance to treatment. Early recurrences are common but usually amenable to further chemical sphincterotomy.

Isolation and characterisation of a full-length genomic clone encoding a plastidic glucose 6-phosphate dehydrogenase from Nicotiana tabacum

We describe here the isolation and characterisation of the first full-length genomic clone encoding a plant glucose 6-phosphate dehydrogenase (G6PDH; EC 1.1.1.49) from Nicotiana tabacum L. cv Samsun. The gene was expressed in all tissues, including roots, leaves, stems and flowers. Comparison of the gene with other known plant G6PDH cDNAs grouped this sequence with plastidic isoforms. The protein, minus a putative plastidic transit sequence, was overexpressed in Escherichia coli as a glutathione S-transferase fusion protein. The resulting protein was shown to be immunologically related to the potato plastidic G6PDH. This suggests that the sequence described here codes for a plastidic isoform. Plastidic G6PDH mRNA was induced in both roots and leaves in response to KNO3, and the induction in roots was approximately 4 times the response seen in leaves. Sequence analysis of the 5'-untranslated region of the genomic clone indicated the presence of several NIT2 elements, which may contribute to the control of the expression of this gene. Plastidic G6PDH mRNA levels did not appear to respond to light.

The bicyclomycin sensitivities of 38 bicyclomycin-resistant mutants of transcription termination protein rho and the location of their mutations support a structural model of rho based on the F(1) ATPase

A total of 38 bicyclomycin-resistant mutants of Escherichia coli transcription termination protein Rho have been isolated. The locations of their mutations identify the ATP-binding region as the functional domain inhibited by bicyclomycin. Strains containing the S266C, S266A and L208R Rho mutations are very resistant to bicyclomycin in vivo. In a similar way, the mutant Rho proteins containing these mutations are very resistant to bicyclomycin in vitro. These data suggest that Ser266 and Leu208 might make direct contact with the antibiotic. These two residues are close to each other in the tertiary structure of a model of Rho based on the alpha and beta subunits of the F(1) ATPase, supporting the validity of the model. The strain containing the G337S Rho mutation also has high bicyclomycin resistance, and the proximity of L208, S266 and G337 in the quaternary structure of the Rho model has enabled a candidate bicyclomycin-binding pocket to be delineated. As a whole, the bicyclomycin sensitivities of the mutants are consistent with the locations of their respective mutations in the model of Rho based on the F(1) ATPase, therefore supporting the emerging consensus model of Rho structure.

Strengths of composite bonded to base metal alloy using dentin bonding systems

STATEMENT OF PROBLEM

Many different bonding systems are currently available that may be used to bond composite to base metal alloy.

PURPOSE

This study measured and compared bond strengths of composite with a base metal alloy using 8 modern dentin bonding systems.

MATERIAL AND METHODS

Base metal alloy buttons were imbedded in acrylic and ground with 120, 400, and 600 grit sandpaper, respectively. Metal surfaces were air abraded for 5 seconds with 50 microm aluminum oxide, washed for 5 seconds under running tap water, then dried with compressed air. Specimens were arbitrarily divided into 8 groups of 10 specimens. Each group was treated with 1 of 8 dentin bonding regimens. A hybrid composite (Herculite) was placed onto the treated metal surface and light polymerized. Specimens were incubated at 37 degrees C in distilled water for 2 hours. Shear bond strengths were measured and the collected data subjected to an ANOVA, followed by multiple t -tests.

RESULTS

All-Bond 2 exhibited the highest mean shear bond strength and Panavia 21 with primer had the lowest in the tests conducted.

CONCLUSION

All-Bond 2 demonstrated significantly higher shear bond strengths over all materials tested, except 3M Single Bond and Optibond FL. No significant difference was noted between the single component and the multicomponent bonding systems.

Decrease of phosphoribulokinase activity by antisense RNA in transgenic tobacco: definition of the light environment under which phosphoribulokinase is not in large excess

To test the hypothesis that the contribution of phosphoribulokinase (PRK) to the control of photosynthesis changes depending on the light environment of the plant, the response of transgenic tobacco (Nicotiana tabacum L.) transformed with antisense PRK constructs to irradiance was determined. In plants grown under low irradiance (330 micromol m(-2) s(-1)) steady-state photosynthesis was limited in plants with decreased PRK activity upon exposure to higher irradiance, with a control coefficient of PRK for CO2 assimilation of 0.25 at and above 800 micromol m(-2) s(-1). The flux control coefficient of PRK for steady-state CO2 assimilation was zero, however, at all irradiances in plant material grown at 800 micromol m(-2) s(-1) and in plants grown in a glasshouse during mid-summer (alternating shade and sun 300-1600 micromol m(-2) s(-1)). To explain these differences between plants grown under low and high irradiances, Calvin cycle enzyme activities and metabolite content were determined. Activities of PRK and other non-equilibrium Calvin cycle enzymes fructose-1,6-bisphosphatase, sedoheptulose-1,7-bisphosphatase and ribulose-1,5-bisphosphate carboxylase-oxygenase were twofold higher in plants grown at 800 micromol m(-2) s(-1) or in the glasshouse than in plants grown at 330 micromol m(-2) s(-1). Activities of equilibrium enzymes transketolase, aldolase, ribulose-5-phosphate epimerase and isomerase were very similar under all growth irradiances. The flux control coefficient of 0.25 in plants grown at 330 micromol m(-2) s(-1) can be explained because low ribulose-5-phosphate content in combination with low PRK activity limits the synthesis of ribulose-1,5-bisphosphate. This limitation is overcome in high-light-grown plants because of the large relative increase in activities of sedoheptulose-1,7-bisphosphatase and fructose-1,6-bisphosphatase under these conditions, which facilitates the synthesis of larger amounts of ribulose-5-phosphate. This potential limitation will have maintained evolutionary selection pressure for high concentrations of PRK within the chloroplast.

Effects of handpiece lubrication on resin-based composite bond strength to enamel

PURPOSE

To evaluate the effects of handpiece lubrication on the bond strengths of resin-based composite (RBC) to enamel using two different bonding systems.

MATERIALS AND METHODS

Sixty extracted noncarious human maxillary incisors were imbedded in acrylic resin tray material with the facial surfaces exposed. 320 grit sandpaper was used to create a flat surface of enamel. The embedded teeth were randomly divided into two bonding systems groups: half used All-Bond 2 and half used OpiBond FL. Within these two groups the teeth were again randomly divided into three subgroups: Dry: 10 teeth prepared with a sterilized unlubricated handpiece; Lube & Run: 10 teeth prepared with a handpiece that was lubricated and run for 30 seconds prior to use; Lube: 10 teeth prepared with a handpiece that was lubricated and not run prior to its use. The enamel was prepared by lightly roughening with a medium grit diamond in the respective handpieces. The preparations were etched for 15 s with 32% phosphoric acid, rinsed with water for 5 s, and dried with compressed air for 5 s. Either bond system was applied and light-cured. A hybrid RBC was placed and light-cured for 60 s. The teeth were stored in water at 37 degrees C 1 week. Shear bond strengths were measured and the collected data subjected to an ANOVA followed by a Tukey's and Bonferroni t-test were performed.

RESULTS

The Dry group and the Lube & Run group had stronger mean shear strengths than did the Lube group. The difference between the mean shear strengths for the Dry group and the Lube & Run group was not statistically significant (P < 0.05). A significant difference was found between the Dry group and the Lube group and between the Lube & Run group and the Lube group (P < 0.05). The mean shear strength for All-Bond 2 was higher than for OptiBond FL (P = 0.0054).

Decrease in phosphoribulokinase activity by antisense RNA in transgenic tobacco. Relationship between photosynthesis, growth, and allocation at different nitrogen levels

To study the direct effects of photosynthesis on allocation of biomass by altering photosynthesis without altering leaf N or nitrate content, phosphoribulokinase (PRK) activity was decreased in transgenic tobacco (Nicotiana tabacum L.) with an inverted tobacco PRK cDNA and plants were grown at different N levels (0.4 and 5 mM NH4NO3). The activation state of PRK increased as the amount of enzyme was decreased genetically at both levels of N. At high N a 94% decrease in PRK activity had only a small effect (20%) on photosynthesis and growth. At low N a 94% decrease in PRK activity had a greater effect on leaf photosynthesis (decreased by up to 50%) and whole-plant photosynthesis (decreased by up to 35%) than at high N. These plants were up to 35% smaller than plants with higher PRK activities because they had less structural dry matter and less starch, which was decreased by 3- to 4-fold, but still accumulated to 24% to 31% of dry weight; young leaves contained more starch than older leaves in older plants. Leaves had a higher ion and water content, and specific leaf area was higher, but allocation between shoot and root was unaltered. In conclusion, low N in addition to a 94% decrease in PRK by antisense reduces the activity of PRK sufficient to diminish photosynthesis, which limits biomass production under conditions normally considered sink limited.

The heat sink and its relationship to reducing heat during pin-reduction procedures

When self-threading pins are used in the restoration of teeth, the heat generated by cutting these pins to the correct length may traumatize the pulp. This study evaluated cotton forceps and a mosquito hemostat used as a heat sink and at different positions on the pin to determine any change in heat transferred to the tooth. Three hundred self-threading pins (Whaledent TMS System: 100 each of the Regular, Minim, and Minikin sizes) were inserted into freshly extracted teeth and sectioned. The temperature change at the apical end of the pin was measured using a thermistor probe. The results indicated that metal supporting instruments can be effective in reducing heat transferred to the apical aspect of the pin during pin reduction.

Azide-sensitive thylakoid membrane insertion of chimeric cytochrome f polypeptides imported by isolated pea chloroplasts

Post-translational integration of cytochrome f into thylakoid membranes was observed after import by isolated pea chloroplasts of a chimeric protein consisting of the presequence of the small subunit of ribulose 1,5-bisphosphate carboxylase fused to the cytochrome f precursor. Import of a similar chimeric protein lacking the C-terminal 33 amino acid residues resulted in a soluble cytochrome f protein in the thylakoid lumen, indicating that the C-terminal region contains a stop-transfer sequence for membrane integration. Azide inhibited the insertion of cytochrome f into the thylakoid membrane, whereas the ionophores nigericin and valinomycin had little effect on membrane insertion. The precursor of the 33 kDa protein, but not the 23 kDa protein, of the photo-system II oxygen-evolving complex inhibited the thylakoid insertion of cytochrome f, suggesting competition for a component of the transport pathway. These experiments suggest that the post-translational insertion of cytochrome f into the thylakoid membrane uses a SecA-dependent pathway.

Manipulating photosynthesis

The levels of individual photosynthetic proteins can be independently decreased by the Agrobacterium-mediated transformation of plants with antisense RNA constructs. Protocols for the introduction of such constructs into Agrobacterium, the Agrobacterium-mediated transformation of tobacco leaf disks, and the screening and analysis of the transgenic plants produced are described.

A matrix solution for severly broken-down teeth

A technique is described for preparation of a dead-soft copper band matrix for tooth restorations. Such a matrix is particularly useful in the restoration of teeth with significant variation in occlusogingival height.

The N-terminal hydrophobic region of the mature phosphate translocator is sufficient for targeting to the chloroplast inner envelope membrane

To locate the sequence required for directing the phosphate translocator to the chloroplast inner envelope membrane, a series of chimeric proteins constituting parts of the phosphate translocator and the small subunit of ribulose-1,5-bisphosphate carboxylase/oxygenase, which is normally located in the stroma, has been produced. Reciprocal exchanges of the presequences and mature sequences of the phosphate translocator and the small subunit indicated that the phosphate translocator presequence contains stromal targeting information and that the mature protein is responsible for inner envelope membrane targeting. Chimeric proteins containing the N-terminal 46 amino acid residues of the phosphate translocator were directed to the inner envelope membrane. Subdivision of this region into its composite hydrophilic and hydrophobic regions showed that the hydrophobic region alone, which consists of amino acid residues 24 to 45, was able to direct the small subunit of ribulose-1,5-bisphosphate carboxylase/oxygenase to the inner envelope membrane.

Alteration of the Amount of the Chloroplast Phosphate Translocator in Transgenic Tobacco Affects the Distribution of Assimilate between Starch and Sugar

Tobacco plants (Nicotiana tabacum L.) transformed with sense and antisense constructs of a cDNA encoding the tobacco phosphate-triose phosphate-3-phosphoglycerate translocator (phosphate translocator) were shown to contain altered amounts of phosphate translocator mRNA and protein. Phosphate translocator activity in intact chloroplasts isolated from transformed plants showed a 15-fold variation, from 20% of the wild-type activity in antisense transformants to 300% of the wild-type activity in sense transformants. However, the maximal rates of photosynthesis and the rates of photosynthetic carbon assimilation in ambient CO2 showed no consistent differences between transformants. Starch content was decreased by 20% and total soluble sugars were increased by 20% in leaves of antisense transformants compared to sense transformants. The 40% decrease in the ratio of starch to total soluble sugars in antisense transformants relative to sense transformants indicates that distribution of assimilate between starch and sugar had been altered. However, the amount of sucrose in the leaves was unchanged. The changes in total soluble sugars were accounted for completely by changes in glucose and fructose, suggesting the existence of a homeostatic mechanism for maintaining sucrose concentrations in the leaves at the expense of glucose and fructose.

Expression of genes encoding the tobacco chloroplast phosphate translocator is not light-regulated and is repressed by sucrose

A cDNA encoding the complete precursor of the phosphate translocator of the chloroplast inner envelope membrane has been isolated from a tobacco leaf (Nicotiana tabacum cv. Samsun) lambda gt 11 library. The tobacco cDNA is 1546 bp in length and encodes a precursor protein of 401 amino acid residues with a deduced molecular weight of 43705. A putative processing site between Ala-73 and Ala-74 of the precursor protein is suggested by comparison with the N-terminal sequences of the pea and spinach proteins. Removal of the transit peptide produces the mature protein of 328 amino acid residues with a molecular weight of 36038. Southern blot analysis suggests there is probably one copy of the phosphate translocator gene in the pea haploid genome and two copies in the tobacco haploid genome, one derived from each ancestral parental genome. Messenger RNAs essentially equivalent in size to the cDNAs (approx. 1.6 kb) were detected in extracts of all organs examined from tobacco and pea, including leaves, stems, sepals, petals, seed-pods, tendrils and roots. An immunochemically related protein of a similar size to the phosphate translocator was detected in the equivalent pea organs. The levels of both mRNA and protein in non-photosynthetic organs were lower than those in photosynthetic organs. Tobacco phosphate translocator mRNA was present at high levels in etiolated tissue and did not increase significantly after 24 h illumination. Germination and growth of tobacco seedlings in the presence of sucrose caused a 3.3-fold decrease in the level of the phosphate translocator mRNA.