Society of American Gastrointestinal and Endoscopic Surgeons guidelines development: health equity update to standard operating procedure

INTRODUCTION

The SAGES Guidelines Committee creates evidence-based clinical practice guidelines. Due to existing health disparities, recommendations made in these guidelines may have different impacts on different populations. The updates to our standard operating procedure described herein will allow us to produce well-designed guidelines that take these disparities into account and potentially reduce health inequities.

METHODS

This paper outlines updates to the SAGES Guidelines Committee Standard Operating Procedure in order to incorporate issues of heath equity into our guideline development process with the goal of minimizing downstream health disparities.

RESULTS

SAGES has developed an evidence-based, standardized approach to consider issues of health equity throughout the guideline development process to allow physicians to better counsel patients and make research recommendations to better address disparities.

CONCLUSION

Societies that promote guidelines within their organization must make an intentional effort to prevent the widening of health disparities as a result of their recommendations. The updates to the Guidelines Committee Standard Operating Procedure will hopefully lead to increased attention to these disparities and provide specific recommendations to reduce them.

A high-throughput amplicon sequencing approach for population-wide species diversity and composition survey

Management of agricultural pests requires an understanding of pest species diversity, their interactions with beneficial insects and spatial-temporal patterns of pest abundance. Invasive and agriculturally important insect pests can build up very high populations, especially in cropping landscapes. Traditionally, sampling effort for species identification involves small sample sizes and is labour intensive. Here, we describe a multi-primer high throughput sequencing (HTS) metabarcoding method and associated analytical workflow for a rapid, intensive, high-volume survey of pest species compositions. We demonstrate our method using the taxonomically challenging Bemisia pest cryptic species complex as examples. The whiteflies Bemisia including the 'tabaci' species are agriculturally important capable of vectoring diverse plant viruses that cause diseases and crop losses. Our multi-primer metabarcoding HTS amplicon approach simultaneously process high volumes of whitefly individuals, with efficiency to detect rare (i.e., 1%) test-species, while our improved whitefly primers for metabarcoding also detected beneficial hymenopteran parasitoid species from whitefly nymphs. Field-testing our redesigned Bemisia metabarcoding primer sets across the Tanzania, Uganda and Malawi cassava cultivation landscapes, we identified the sub-Saharan Africa 1 Bemisia putative species as the dominant pest species, with other cryptic Bemisia species being detected at various abundances. We also provide evidence that Bemisia species compositions can be affected by host crops and sampling techniques that target either nymphs or adults. Our multi-primer HTS metabarcoding method incorporated two over-lapping amplicons of 472bp and 518bp that spanned the entire 657bp 3' barcoding region for Bemisia, and is particularly suitable to molecular diagnostic surveys of this highly cryptic insect pest species complex that also typically exhibited high population densities in heavy crop infestation episodes. Our approach can be adopted to understand species biodiversity across landscapes, with broad implications for improving trans-boundary biosecurity preparedness, thus contributing to molecular ecological knowledge and the development of control strategies for high-density, cryptic, pest-species complexes.

On species delimitation, hybridization and population structure of cassava whitefly in Africa

The Bemisia cassava whitefly complex includes species that cause severe crop damage through vectoring cassava viruses in eastern Africa. Currently, this whitefly complex is divided into species and subgroups (SG) based on very limited molecular markers that do not allow clear definition of species and population structure. Based on 14,358 genome-wide SNPs from 62 Bemisia cassava whitefly individuals belonging to sub-Saharan African species (SSA1, SSA2 and SSA4), and using a well-curated mtCOI gene database, we show clear incongruities in previous taxonomic approaches underpinned by effects from pseudogenes. We show that the SSA4 species is nested within SSA2, and that populations of the SSA1 species comprise well-defined south-eastern (Madagascar, Tanzania) and north-western (Nigeria, Democratic Republic of Congo, Burundi) putative sub-species. Signatures of allopatric incipient speciation, and the presence of a 'hybrid zone' separating the two putative sub-species were also detected. These findings provide insights into the evolution and molecular ecology of a highly cryptic hemipteran insect complex in African, and allow the systematic use of genomic data to be incorporated in the development of management strategies for this cassava pest.

Validation of a novel patient-reported outcome measure for parathyroid and thyroid disease (PROMPT)

BACKGROUND

Patient-reported outcome measures are being used increasingly to assess disease severity and response to surgery. The purpose of this study was to create and validate a patient-reported outcome measure for symptoms of thyroid enlargement and hyperparathyroidism, 2 conditions where the presence of preoperative symptoms and response to surgery is often questioned.

METHODS

A questionnaire reviewing common symptoms was developed from a literature review and expert opinion. Internal validity, reliability, and initial responsiveness to surgery were evaluated.

RESULTS

Patient-Reported Outcome Measure for Parathyroid and Thyroid Disease (PROMPT) consists of 30 items: 10 compressive items and 20 hyperparathyroidism items; we evaluated 302 surveys collected over 10 months. PROMPT showed high internal consistency for compressive and hyperparathyroid constructs (Cronbach's α 0.84 and 0.95). Constructs were scored from 0-100, with greater scores corresponding to increased severity of symptoms. Preoperatively, patients with a goiter demonstrated greater compressive scores compared with other thyroid patients and hyperparathyroid patients (goiter, 47.5; nodule/other, 38.4; hyperparathyroid, 29.8; P < .0001). PROMPT demonstrated high test-retest reliability with acceptable intraclass correlation coefficients for both compressive score and hyperparathyroid score (0.840 and 0.646). Hyperparathyroid scores improved 2 weeks after (48.6 postop, 44.0 preop, P = .0470).

CONCLUSION

We validated a novel measure for symptoms of hyperparathyroidism and goiter. PROMPT demonstrates high internal consistency, test-retest reliability, and preliminary analysis, which suggests that it is sensitive to change after surgery.

Utilization of Quality Improvement Methodology to Standardize Communication of Outside Hospital Transfers in a General Surgery Program

OBJECTIVE

There is no standardized method of communication regarding the arrival of outside hospital (OSH) transfers at our institution. We utilized quality improvement methodologies to enhance sign-out, benefiting both resident workflow and patient care.

DESIGN

A dynamic census log of pending OSH transfers was created. Total number of OSH transfers (with or without prior notification), time to admission orders, and resident self-reported preparedness in receiving/triaging OSH admissions were measured before and after implementation of the census log tool.

SETTING

Quaternary referral hospital in Cleveland, Ohio.

PARTICIPANTS

The census log was made available to General Surgery residents on receiving surgical teams. After the data collection period, it was made available to all residents in the program.

RESULTS

A total of 93 patients were transferred to receiving surgical teams during our 13-week study period. Resident notification of the OSH transfer prior to patient's arrival increased from 44.7% pre- to 70.3% postimplementation of the tool (p = 0.03). When residents received prior notification of pending transfers, time to place admission orders decreased from 81.2 ± 79.9 minutes to 40.4 ± 36.8 minutes (p = 0.0029). Junior residents' self-reported preparedness in admitting an OSH transfer did not significantly differ when they received prior notification versus when they did not. In contrast, senior residents' self-reported higher levels of preparedness in the instances where they received prior notification of a pending transfer.

CONCLUSIONS

In light of the recent Clinical Learning Environment Review program set forth by the Accreditation Council for Graduate Medical Education, trainees are expected to engage in improvement processes as it relates to patient safety and transitions of care. The development and implementation of our tool demonstrate that quality improvement methodologies can be effectively applied to resident workflow challenges, improving both trainee education and patient care.

Cassava whitefly, Bemisia tabaci (Gennadius) (Hemiptera: Aleyrodidae) in East African farming landscapes: a review of the factors determining abundance

Bemisia tabaci (Gennadius) (Hemiptera: Aleyrodidae) is a pest species complex that causes widespread damage to cassava, a staple food crop for millions of households in East Africa. Species in the complex cause direct feeding damage to cassava and are the vectors of multiple plant viruses. Whilst significant work has gone into developing virus-resistant cassava cultivars, there has been little research effort aimed at understanding the ecology of these insect vectors. Here we assess critically the knowledge base relating to factors that may lead to high population densities of sub-Saharan African (SSA) B. tabaci species in cassava production landscapes of East Africa. We focus first on empirical studies that have examined biotic or abiotic factors that may lead to high populations. We then identify knowledge gaps that need to be filled to deliver sustainable management solutions. We found that whilst many hypotheses have been put forward to explain the increases in abundance witnessed since the early 1990s, there are little published data and these tend to have been collected in a piecemeal manner. The most critical knowledge gaps identified were: (i) understanding how cassava cultivars and alternative host plants impact population dynamics and natural enemies; (ii) the impact of natural enemies in terms of reducing the frequency of outbreaks and (iii) the use and management of insecticides to delay the development of resistance. In addition, there are several fundamental methodologies that need to be developed and deployed in East Africa to address some of the more challenging knowledge gaps.

Addressing Professionalism, Social, and Communication Competencies in Surgical Residency Via Integrated Humanities Workshops: A Pilot Curriculum

OBJECTIVE

We aimed to conduct professionalism and social competencies (PSC) training by integrating humanities into structured workshops, and to assess reception of this curriculum by first-year surgical residents.

DESIGN

An IRB-approved, pilot curriculum consisting of 4 interactive workshops for surgical interns was developed. The workshops were scheduled quarterly, often in small group format, and supplemental readings were assigned. Humanities media utilized to illustrate PSC included survival scenarios, reflective writing, television portrayals, and social media. Emphasis was placed on recognizing personal values and experiences that influence judgment and decision-making, using social media responsibly, identifying and overcoming communication barriers related to generational changes in training (especially technology and work-life balance), and tackling stereotypes of surgeons. Anonymous and voluntary pre- and postcurriculum surveys were administered. Univariate analysis of responses was performed with JMP Pro v12 using Fisher's exact, χ², and Students' t-tests for categorical and continuous variables.

SETTING

The study took place at the Cleveland Clinic in Cleveland, OH, within the general surgery program.

PARTICIPANTS

Surgical interns at the Cleveland Clinic were included in the study. A total of 16 surgical interns completed the curriculum.

RESULTS

Sixteen surgical interns participated in the curriculum: 69% were domestic medical school graduates (DG) and 31% were international medical school graduates (IMG). Overall, the majority (81%) of residents had received PSC courses during medical school: 100% of DG compared to 40% of IMG (p = 0.02). Before beginning the curriculum, 86% responded that additional PSC training would be useful during residency, which increased to 94% upon completion (p = 0.58). Mean number of responses supporting the usefulness of PSC training increased from 1.5 ± 0.2 before the curriculum to 1.75 ± 0.2 upon completion (p = 0.4). When describing public and medical student perceptions of surgeons, 60% and 83% of adjectives used were negative, respectively. When describing perceptions of female surgeons, 88% of adjectives used were negative.

CONCLUSIONS

Most interns received prior PSC coursework; however, the majority still desired additional training during residency. After completion, a greater percentage of interns responded that PSC training was important and choose more reasons in favor of the curriculum. Formalized didactics should be strongly considered, especially in programs with IMG. Future areas of investigation include expanding the cohort to additional years of residency; potentially identifying unique PSC needs for each postgraduate year.

Surgical Management of Parastomal Hernias

Parastomal hernias are a common complication after ostomy formation that can require surgical repair when they become symptomatic. Operative planning and a thorough understanding of the anatomy of the abdominal wall are important. Simple fascial repair is associated with an unacceptably high recurrence rate and should be used as a temporary measure only. Stoma relocation has a high recurrence rate. Prophylactic mesh can and should be used. At this time, the use of mesh is considered the standard of care in the repair of parastomal hernias.

The utility of indocyanine green fluorescence imaging during robotic adrenalectomy

BACKGROUND AND OBJECTIVES

Indocyanine green (ICG) has been used for medical imaging since 1950s, but has more recently become available for use in minimally invasive surgery owing to improvements in technology. This study investigates the use of ICG florescence to guide an accurate dissection by delineating the borders of adrenal tumors during robotic adrenalectomy (RA).

METHODS

This prospective study compared conventional robotic view with ICG fluorescence imaging in 40 consecutive patients undergoing RA. Independent, non-blinded observers assessed how accurately ICG fluorescence delineated the borders of adrenal tumors compared to conventional robotic view.

RESULTS

A total of 40 patients underwent 43 adrenalectomies. ICG imaging was superior, equivalent, or inferior to conventional robotic view in 46.5% (n = 20), 25.6% (n = 11), and 27.9% (n = 12) of the procedures. On univariate analysis, the only parameter that predicted the superiority of ICG imaging over conventional robotic view was the tumor type, with adrenocortical tumors being delineated more accurately on ICG imaging compared to conventional robotic view.

CONCLUSIONS

This study demonstrates the utility of ICG to guide the dissection and removal of adrenal tumors during RA. A simple reproducible method is reported, with a detailed description of the utility based on tumor type, approach and side. J. Surg. Oncol. 2016;114:153-156. © 2016 Wiley Periodicals, Inc.

A phase I/II trial of bortezomib combined concurrently with gemcitabine for relapsed or refractory DLBCL and peripheral T-cell lymphomas

There remains an unmet therapeutic need for patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL) and peripheral T-cell lymphoma (PTCL). We conducted a phase I/II trial with bortezomib (dose-escalated to 1·6 mg/m(2) ) given concurrently with gemcitabine (800 mg/m(2) ) days 1 + 8 q21 d. Of 32 patients, 16 each had relapsed/refractory PTCL and DLBCL. Median prior therapies were 3 and 35% had failed transplant. Among the first 18 patients, 67% experienced grade 3/4 neutropenia and/or grade 3/4 thrombocytopenia resulting in repeated treatment delays (relative dose intensity: 46%). Thus, the study was amended to give bortezomib and gemcitabine days 1 + 15 q28 d, which resulted in markedly improved tolerability. Among all patients, the overall response rate (ORR) was 24% with 19% complete remission (CR; intent-to-treat (ITT) ORR 16%, CR 13%), which met criteria for futility. The ORR for DLBCL was 10% (CR 10%) vs. 36% for PTCL (CR 27%). Among 6 PTCL patients treated on the modified schedule, ORR by ITT was 50% (CR 30%). Altogether, concurrent bortezomib/gemcitabine given days 1 + 8 q21 d was not tolerable, while modification to a bi-monthly schedule allowed consistent treatment delivery. Whereas efficacy of this combination was low in heavily pre-treated DLBCL, there was a signal of activity in relapsed/refractory PTCL utilizing the modified schedule.

Quantitative trait loci linked to thalamus and cortex gray matter volumes in BXD recombinant inbred mice

To investigate whether there are separate or shared genetic influences on the development of the thalamus and cerebral cortex, we identified quantitative trait loci (QTLs) for relevant structural volumes in BXD recombinant inbred (RI) strains of mice. In 34 BXD RI strains and two parental strains (C57BL/6J and DBA/2J), we measured the volumes of the entire thalamus and cortex gray matter using point counting and Cavalieri's rule. Heritability was calculated using analysis of variance (ANOVA), and QTL analysis was carried out using WebQTL (http://www.genenetwork.org). The heritability of thalamus volume was 36%, and three suggestive QTLs for thalamus volume were identified on chromosomes 10, 11 and 16. The heritability of cortical gray matter was 43%, and four suggestive QTLs for cortex gray matter volume were identified on chromosomes 2, 8, 16 and 19. The genetic correlation between thalamus and cortex gray matter volumes was 0.64. Also, a single QTL on chromosome 16 (D16Mit100) was identified for thalamus volume, cortex gray matter volume and Morris water maze search-time preference (r=0.71). These results suggest that there are separate and shared genetic influences on the development of the thalamus and cerebral cortex.

Re-emergence of Cassava Brown Streak Disease in Uganda

During November 2004, veinal chlorosis on mature cassava leaves, typical of cassava brown streak disease (CBSD), was observed at Mukono in central Uganda. Five out of 11 cultivars at the site showed CBSD symptoms (incidence range 4 to 64%). In a survey of farmers' fields, CBSD was observed in Wakiso and Mukono districts. Incidence of cassava mosaic disease was also recorded and averaged 60% for landraces (range 16.7 to 100%) and 20% for resistant varieties (range 0 to 65%). Leaf samples of plants with CBSD symptoms produced an amplicon of 222 bp using reverse transcription-polymerase chain reaction with primers that amplify a fragment of the coat protein (CP) gene of Cassava brown streak virus. Sequence comparisons based on the amplified CP gene fragment indicated that the isolates have 77 to 82.9% nucleotide and 43.9 to 56.8% amino acid identity with those from Mozambique and Tanzania. There was 95.9 to 99.5% nucleotide and 85.1 to 90.5% amino acid identity among the Ugandan isolates. These results confirm the re-emergence of CBSD in Uganda after it was first observed in the 1930s in cassava introduced from Tanzania and controlled by eradication. Prior to this report, CBSD was known to be restricted to the coastal lowlands of East Africa.

PCR-based detection and partial genome sequencing indicate high genetic diversity in Bangladeshi begomoviruses and their whitefly vector, Bemisia tabaci

The population diversity of Bangladeshi begomoviruses and their vector, Bemisia tabaci was analysed by PCR-based detection and partial genome sequencing. B. tabaci adults and plants expressing symptoms of virus infection were collected from locations representing diverse agro-ecological regions of the country. Universal and species-specific primers were used to detect begomoviruses in seven crops (chilli, okra, papaya, pumpkin, sponge gourd, tomato and yardlong bean) and two common weeds (Ageratum conyzoides and Croton bonplandianum). At least five distinct species of tomato leaf curl viruses infected tomato and other host-plants. Phylogenetic analyses of their nucleotide sequences ( approximately 530 bases) from the intergenic region and capsid protein of DNA-A indicated the existence of five distinct clusters of begomoviruses. Begomoviruses infecting tomato, chilli and dolichos have been reported previously, and those infecting Ageratum, Croton, okra, papaya, pumpkin and yardlong bean are described for the first time. Phylogenetic analyses based on mitochondrial cytochrome oxidase I gene sequences of 21 B. tabaci from Bangladesh and other reference sequences grouped them into at least two independent clusters. Some sequences from different countries, e.g., Bangladesh, China, India, Nepal, Pakistan and Thailand were almost identical while others collected from plants within the same field diverged by as much as 15%, indicating high diversity even at the local level. None of the B. tabaci from Bangladesh grouped with the reference B- and Q-biotype sequences, thus these two aggressive biotypes were apparently absent from Bangladesh.

Nucleotide sequencing, whitefly transmission, and screening tomato for resistance against two newly described begomoviruses in bangladesh

ABSTRACT The molecular diversity of Tomato leaf curl viruses (ToLCVs), from the two main tomato growing areas of Jessore and Joydebpur, Bangladesh, was investigated. The viral DNA was amplified from tomato plants exhibiting mild and severe symptoms by polymerase chain reaction, and the complete genomes of the ToLCVs were sequenced. An isolate of the bipartite Tomato leaf curl New Delhi virus-Severe (ToLCNDV-Svr) was associated with the severe symptom phenotype from Jessore (ToLCNDV-Svr[Jes]). A previously undescribed monopartite virus, designated Tomato leaf curl Joydebpur virus-Mild (ToLCJV-Mld), was sequenced from plants showing mild symptoms. ToLCNDV-Svr[Jes] was most closely related to ToLCNDV-[Lucknow] at 95.7% nucleotide (nt) identity and Tomato leaf curl Gujarat virus-[Varanasi] at 90.6% nt identity, based on DNA-A and -B component sequences. ToLCJV-Mld was similar to Pepper leaf curl Bangladesh virus at 87.1% DNA-A nt identity. Identification of ToLCNDV-Svr[Jes] and ToLCJV-Mld was in addition to the previously described Tomato leaf curl Bangladesh virus, with which they shared 73.2 and 86.0% DNA-A nt identities, thus demonstrating the existence of at least three distinct viruses infecting tomato in Bangladesh. Nucleotide identities and placement in phylogenetic trees suggested that the three ToLCVs may have had different evolutionary pathways. The whitefly, Bemisia tabaci, transmitted the viruses of this study equally efficiently. Four tomato cultivars (TLB111, TLB130, TLB133, and TLB182) resistant/ tolerant to South Indian ToLCV were screened against the Bangladesh ToLCVs in 2003-04. Although challenged by diverse viruses and potentially mixed infections, disease incidence remained low (6 to 45%) in the resistant cultivars compared with local cultivars (68 to 100%).

First Report of Tomato leaf curl New Delhi virus Infecting Tomato in Bangladesh

Tomato is an important cash crop for resource-poor farmers and accounts for 20% of the 2 million t of vegetables grown annually in Bangladesh. Tomato cultivation is affected by Tomato leaf curl virus (ToLCV), which can cause as much as 100% yield loss. Plants exhibiting typical ToLCV disease symptoms of yellowing, severe leaf curling, and stunting were collected at Jessore, Bangladesh during September 2003. The putative virus was transmitted from tomato to tomato by the whitefly Bemisia tabaci. In two separate experiments, 100% transmission was achieved by using 10 viruliferous B. tabaci adults for each of the 20 test plants that was confirmed by comparing the symptoms on test and virus source plants. Total DNAs were extracted from the symptomatic leaves, and the putative viral genomes were amplified by polymerase chain reaction by using the Deng A and B primers (1). Sequences generated from these primers were used to design virus-specific primers that were used to obtain complete viral sequences. Full-length DNA-A (2,740 nt; GenBank Accession No. AJ875157) and DNA-B (2,688 nt; GenBank Accession No. AJ875158) sequences of a bipartite Tomato leaf curl New Delhi virus from Jessore (ToLCNDV-[Jes]) were obtained, which were most similar to the corresponding sequences of ToLCNDV-(Lucknow) (GenBank Accession No. Y16421) at 95.7% and Tomato leaf curl Gujarat virus-(Varanasi) (Gen-Bank Accession No. AY190291) at 90.6% nt identities, respectively. DNA-A sequences had only 73.2% nt identity with the previously reported monopartite Tomato leaf curl Bangladesh virus (GenBank Accession No. AF188481) (2), confirming the occurrence of mono- and bipartite bego-moviruses in Bangladesh. The virus diversity poses a challenge for ToLCVD management in Bangladesh. References: (1) D. Deng et al. Ann. Appl. Biol. 125:327, 1994. (2) S. K. Green et al. Plant Dis. 85:1286, 2001.

Pall eBDS: an enhanced bacterial detection system for screening platelet concentrates

Bacterial contamination of blood components remains a significant problem in transfusion medicine. The Pall enhanced bacterial detection system (Pall eBDS) detects the presence of bacteria in leucodepleted platelet concentrates by measuring the reduction of oxygen in the sample, due to aerobic bacterial growth. Pooled platelet concentrates were spiked at 10 cfu mL(-1) with 10 organisms (one species per bag). Pall eBDS pouches were inoculated with the spiked platelet concentrates. After 24 and 30 h of incubation, the oxygen level was measured. A further set of pouches were taken from the inoculated platelet concentrates at 24 h. Incubation and reading intervals were as for the initial set of pouches. A sensitivity study was also performed comparing the Pall eBDS with the BacT/ALERT system. Spiking at 10 cfu mL(-1) and immediately sampling into Pall eBDS pouches resulted in 97.6 and 100% detection after an incubation period of 24 and 30 h, respectively. After 24 h of incubation of the spiked platelet concentrates and then sampling into Pall eBDS pouches, 99.1% detection was obtained after incubation for both 24 and 30 h. The sensitivity of the Pall eBDS and BacT/ALERT is similar and in the order of 1 cfu mL(-1). Implementation of either BacT/ALERT or Pall eBDS for routine screening of platelet concentrates has the potential to further increase the safety of the blood supply.

Use of a solid-phase fluorescent cytometric technique for the detection of bacteria in platelet concentrates

Blood services worldwide are now striving to reduce the risk of transmission of bacteria by transfusion. The BacT/ALERT microbial detection system (bioMerieux, Basingstoke, Hants, UK) is currently regarded as the 'gold standard' for bacterial screening of platelet concentrates. The BacT/ALERT is a culture system and will not generate an 'instant' (within 2 h) determination. We report on the Scansystem (Hemosystem, Marseille, France), a solid-phase fluorescent cytometric technique, which enables the rapid detection of bacteria (within 90 min) in platelet concentrates. The study was performed in two parts - one involving the routine screening of platelet concentrates and the other determining the sensitivity of the system. In both arms of the study, the BacT/ALERT was used for comparative purposes. In total, 900 platelet concentrates were screened (63 apheresis and 837 buffy coat pooled). No bacteria were detected in any of the platelet concentrates tested by means of either the Scansystem or the BacT/ALERT. The sensitivity of the Scansystem was in the order of 10(3) cfu mL(-1). Escherichia coli and Staphylococcus aureus were detected by using the Scansystem at 1 cfu mL(-1). The BacT/ALERT detected all organisms tested (n = 6) at 1 cfu mL(-1). The Scansystem offers a sensitive alternative technology to bacterial culture, with the benefit of a rapid test time.

Incidence of lower thoracic ligamentum flavum midline gaps † †Presented in abstract form at the IARS 78th Clinical and Scientific Congress, Tampa Bay, Florida, USA, 2004

BACKGROUND

Lower thoracic epidural anaesthesia and analgesia (EDA) has gained increasing importance in perioperative pain therapy. The loss-of-resistance technique used to identify the epidural space is thought to rely on the penetration of the ligamentum flavum. Investigations at the cervical and lumbar regions have demonstrated that the ligamentum flavum frequently exhibits incomplete fusion at different vertebral levels. Therefore, the aim of this study was to directly investigate the incidence of lower thoracic ligamentum flavum midline gaps in embalmed cadavers.

METHODS

Vertebral column specimens were obtained from 47 human cadavers. Ligamentum flavum midline gaps were recorded between the vertebral levels T6 and L1.

RESULTS

The incidence of midline gaps/number of viable specimens at the following levels was: T6-7: 2/45 (4.4%), T7-8: 1/47 (2.1%), T8-9: 2/45 (4.4%), T9-10: 7/39 (17.9%), T10-11: 12/34 (35.2%), T11-12: 10/35 (28.5%), T12/L1: 6/38 (15.8%).

CONCLUSIONS

In the present study we have determined the frequency of lower thoracic ligamentum flavum midline gaps. Gaps are less frequent than at cervical levels, but more frequent than at lumbar levels. Peak incidence was found in the region between T10 and T12. Using a strict midline approach, one cannot therefore rely on the ligamentum flavum to impede entering the epidural space in all patients.

Diversity and distribution of begomoviruses infecting tomato in India

Leaf curl begomoviruses cause serious yield losses to Indian tomato crops. Total DNAs were extracted from leaves of 69 tomato plants and 34 weeds or neighbouring crops collected from all the major tomato producing areas of India. Eighty-one of the 103 samples were positive by PCRs using begomovirus genus-specific primers. Coat protein (CP) genes from 29 samples were PCR amplified, cloned and sequenced. Phylogenetic analyses of the CP sequences revealed five different tomato leaf curl begomovirus (TLCB) clusters each <88% identity to the others. Four clusters represented known Indian TLCBs, whereas one cluster contained sequences originating from Haryana State with most identity (89%) to the provisional Begomovirus species Croton yellow vein mosaic virus.Sixty-five begomovirus positive samples were characterised further by PCR with DNA-beta, DNA-B, four Indian TLCB species, PALIc1960/PARIv722 (universal begomovirus primers), and by sequencing. The majority of samples represented monopartite TLCBs associated with DNA-beta components. All four known TLCBs appeared to be present throughout India. TLCBs were also present in chilli, cowpea, okra and tobacco crops, as well as in some common weeds. Papaya leaf curl virus and Pepper leaf curl Bangladesh virus sequences were detected in tomato. Mixed begomovirus infections, a prerequisite for recombination, were evident in 13 samples.

A novel method for the detection of bacteria in platelet concentrates utilizing oxygen consumption as a marker for bacterial growth

Bacterial transfusion-transmission remains a significant problem in transfusion medicine. Diversion and improved donor arm disinfection has been introduced by blood services to reduce bacterial transmissions. These interventions are not 100% effective and, therefore, there is still a requirement to screen blood donations, particularly platelet concentrates which are responsible for the majority of transmissions. Pall BDS, a novel bacterial testing system, detects the presence of bacteria in platelet concentrates by measuring the reduction in oxygen content associated with bacterial growth. Buffy coat-derived pooled platelet concentrates were spiked with 12 aerobic and two anaerobic organisms (one species per bag, n = 10) at 100-700 cfu mL(-1). Samples were taken into Pall BDS sample pouches and incubated for 0, 24, 30 and 48 h. An initial incubation was undertaken at 35 degrees C for 24 h and subsequent incubation was at 22 degrees C. At the end of the incubation period the oxygen content in the Pall BDS pouches was measured using a gas analyser. An oxygen content less than or equal to 19.5% was deemed to be positive. Pall BDS pouches tested positive in 80, 94 and 98% units spiked with aerobic bacteria at 24, 30 and 48 h, respectively. Anaerobic bacteria were not detected by the system. Positive BDS pouches contained 10(6) cfu mL(-1) or greater. The system was simple and easy to perform. Pall BDS has a closed sampling system which prevents exogenous contamination. This initial study indicates that the Pall BDS offers a practicable system for detecting bacteria present in leucodepleted platelet concentrates.

East African cassava mosaic Zanzibar virus - a recombinant begomovirus species with a mild phenotype

Cassava plants exhibiting mild symptoms of cassava mosaic disease (CMD) were collected from Unguja island, Zanzibar. Cuttings grown from these plants in the glasshouse produced similar symptoms, which were milder than those caused by other known cassava mosaic geminiviruses (CMGs). The whitefly vector, Bemisia tabaci (Gennadius), transmitted the putative virus to 27.7% (n = 18) of target plants. Total DNA extracted from diseased leaves did not yield diagnostic PCR-bands using virus-specific primers to known CMGs. Degenerate primers, however, produced a diagnostic band indicating the presence of a begomovirus. Full-length DNA-A (2785 nucleotides) and DNA-B (2763 nucleotides) components were subsequently PCR-amplified, cloned and sequenced. Phylogenetic analyses of DNA-A and -B sequences showed that they were most similar to strains of East African cassava mosaic virus from Tanzania and Uganda at 83% and 86% nucleotide identities, respectively. The number and arrangement of open reading frames were similar to those of bipartite begomoviruses from the Old World. DNA-A was predicted to have recombined in the intergenic region (IR), AC1 and AC4 genes, and DNA-B in the IR. A maximum nucleotide identity of 83% in the DNA-A component with other sequenced begomoviruses, together with different biological properties allows this virus to be recognised as belonging to a new species named East African cassava mosaic Zanzibar virus (EACMZV).

Unintentional arterial puncture during cephalic vein cannulation: case report and anatomical study †

BACKGROUND

The cephalic antebrachial vein is often used for venous access. However, superficial radial arteries of the forearm are known and unintentional arterial puncture can result from attempts to cannulate the lateral veins of the arm.

METHODS

Accidental puncture of a superficial radial artery during peripheral venous cannulation prompted us to study the anatomy of 26 specimens and to assess the relationship between the radial artery and the cephalic vein in the forearm.

RESULTS

In two cases, we found accessory branches of the radial artery close to the cephalic forearm vein. Venous cannulation at the lateral wrist carries a small risk of arterial puncture if arterial anomalies are present.

CONCLUSIONS

If venous cannulation is attempted at the radial side of the wrist, palpation for pulsation should reduce the danger of arterial puncture.

Accuracy in estimating the correct intervertebral space level during lumbar, thoracic and cervical epidural anaesthesia

BACKGROUND

Even in the absence of factors concealing anatomical landmarks, high failure rates in correctly determining a given lumbar interspace have been reported.

METHODS

Therefore, it was the aim of the present study to compare the assessed and factual level (determined by computed tomography) of epidural puncture in attending a regional anaesthesia cadaver workshop. Eighty-two anaesthetists performed 117 punctures.

RESULTS

Vertebral interspaces between T8-L4 were correctly identified more often than those between C3-T5 (P < 0.05). Identification of an arbitrarily chosen vertebral interspace was excellent in both the cervical/high thoracic and thoracic/lumbar regions.

CONCLUSION

As previously conjectured only for the lumbar region, we could confirm the tendency of anaesthetists to perform neuraxial puncture more cranially than expected also for the thoracic and cervical regions. The large majority of punctures (93.7%) was performed within one interspace of the predicted level.

Laser-driven plasma loader for shockless compression and acceleration of samples in the solid state

A new method for shockless compression and acceleration of solid materials is presented. A plasma reservoir pressurized by a laser-driven shock unloads across a vacuum gap and piles up against an Al sample thus providing the drive. The rear surface velocity of the Al was measured with a line VISAR, and used to infer load histories. These peaked between approximately 0.14 and 0.5 Mbar with strain rates approximately 10(6)-10(8) s(-1). Detailed simulations suggest that apart from surface layers the samples can remain close to the room temperature isentrope. The experiments, analysis, and future prospects are discussed.

Co-adaptation between cassava mosaic geminiviruses and their local vector populations

Four cassava mosaic geminivirus (CMG) isolates; African cassava mosaic virus from Namulonge, Uganda (ACMV-[Nam]), East African cassava mosaic virus from Mtwara, Tanzania (EACMV-[Mtw]), EACMV-Uganda from Namulonge (EACMV-UG[Nam]) and Indian cassava mosaic virus from Trivandrum, India (ICMV-[Tri]) were compared for their ability to be transmitted by four colonies of cassava whitefly, Bemisia tabaci (Gennadius), collected from Namulonge (NAM), Mtwara (MTW), Kumasi (KUM) and Trivandrum (TRI). With 20 adult whiteflies per test plant, the CMGs from Africa were transmitted by all three of the African B. tabaci populations to 60-79% of the target plants. Indian cassava B. tabaci transmitted ICMV-[Tri] to 89% of the target plants. In contrast, Indian cassava B. tabaci transmitted EACMV-[Mtw] and Tanzanian cassava B. tabaci transmitted ICMV-[Tri] less than a tenth as often, even when using 50 adults per plant and with increased acquisition and inoculation access periods. The complete coat protein genes of the CMGs had sequences typical of their source viruses, the major differences occurring between those originating from India and Africa. Symptom severity of the CMGs was quantified precisely by both visual assessment and image analysis techniques. EACMV-[Mtw] and ACMV-[Nam] were the most and least damaging isolates with 15.4 and 10.0% of the leaf area diseased, respectively. In these tests the transmission frequency was not linked to symptom severity in the source plants. These data support the hypothesis that virus-vector co-adaptation exists in the cassava mosaic disease (CMD) pathosystem and the results are discussed in relation to CMD epidemiology.

First Report of a Distinct Begomovirus Infecting Cassava from Zanzibar

In 1998, cassava plants exhibiting extremely mild mosaic disease symptoms were collected from Uguja Island, Zanzibar. Total DNAs extracted from symptomatic leaves did not produce diagnostic PCR bands using primers specific to known Cassava mosaic viruses (genus Begomovirus, family Geminiviridae) (2). Degenerate primer pair A/B (1), however, produced a 564-nucleotide (nt) band in the common region of DNA-A to the conserved amino acid sequence CEGPCKYG within the coat protein gene for begomoviruses. Virus-specific primers were designed and the begomoviral genome was amplified and cloned to obtain the full-length DNA-A (2,785 nt) (AF422174) and the partial DNA-B (2,403 nt) (AF422175) component comprising the 5' end of the BV1 open reading frame (ORF) to eight (A) of the conserved nanonucleotide TAATATTAC in the common region. Phylogenetic comparisons of DNA-A and -B sequences of the cassava begomivirus showed they were most closely related to East African cassava mosaic virus (EACMV) from Tanzania (Z83256, 83% identity) and Uganda (AF126805, 87% identity). Based on DNA-A and -B components, its closest relatives among African cassava mosaic virus strains were the Nigerian (X17095, 67% identity) and Ugandan (AF126800, 38% identity) isolates respectively. The number and arrangement of the viral ORF was identical to other bipartite begomoviruses from the Old World. Work is in progress to determine whether this begomovirus is a new strain of an existing EACMV or a new species. References: (1) D. Deng et al. Ann. App. Biol. 125:327, 1994. (2) X. Zhou et al. J. Gen. Virol. 78:2101, 1997.

Inferior vena caval loop of an endocardial pacing lead did not solve the growth problem in a child

This report describes a transvenous pacemaker lead insertion into a child's right ventricle with a loop formed within the inferior vena cava to allow growth. Five years later emergency revision was necessary because of loss of capture. The expected lead release had not taken place.

First Report of the Bemisia tabaci B Biotype in India and an Associated Tomato leaf curl virus Disease Epidemic

In May 1999, in the Kolar district of Karnataka State, Bemisia tabaci numbers on tomato increased by approximately 1,000-fold that observed previously (3). This was associated with an epidemic of severe tomato leaf curl disease that caused complete crop failure. DNAs extracted from 35 symptomatic tomato leaf samples collected within the epidemic region all gave the expected 500 to 600 bp amplicon with begomovirus-specific primers A/B (1). These primers amplify from the conserved nonanucleotide TAATATTAC in the common region of DNA-A to the conserved amino acid sequence CEGPCKYG within the coat protein gene. AluI and TaqI restriction patterns of all 35 polymerase chain reaction (PCR) products were identical. One PCR product from an epidemic (GenBank no. AF321929) and a non-epidemic (AF321930) site (Bangalore) were cloned and sequenced. The two 531-bp inserts showed 96% nucleotide identity to each other and 94% nucleotide identity to the equivalent region of Tomato leaf curl Bangalore virus (ToLCBV-Ban-4) (AF165098), suggesting that the epidemic was caused by an indigenous ToLCBV strain. Adult B. tabaci were collected from tomato plants at nine sites within the epidemic. DNA was extracted from 9 to 13 individuals per site and analyzed by RAPD-PCR using primers OpB20 and OpB11. Eighty to 100% of individuals per site had identical patterns to those of B biotype individuals from Israel and Florida, which were different to the patterns produced by the indigenous Indian B. tabaci. Adult B. tabaci from the epidemic and nonepidemic (Bangalore) regions were cultured separately on zucchini plants (n = 20) vars. Fordhook and Ambassador. Distinct silverleaf symptoms appeared in all plants fed on by the epidemic B. tabaci, but not on those fed on by the nonepidemic whiteflies. Irregular ripening of tomatoes was also a widespread problem in the epidemic area. Cytochrome oxidase I (COI) (720 bp) gene sequences were obtained for epidemic (AF321927) and nonepidemic (AF321928) B. tabaci, which had only 80% nucleotide identity to each other. A GenBank BLAST search showed that the former were most similar to B biotype whitefly from Israel (AF164667; 97%) and Texas (AF164675; 99%). The B biotype transmits Indian ToLCBV (2) and its introduction into India is of great concern as it is already associated with a devastating plant-disease epidemic. References: (1) D. Deng et al. Ann. App. Biol. 125:327, 1994. (2) P. F. McGrath and B. D. Harrison. Ann. App. Biol. 126:307, 1995. (3) H. K. Ramappa et al. Ann. App. Biol. 133:187, 1998.

Biomechanical evaluation of a prototype foot/ankle prosthesis

In this paper, we report on our pilot evaluation of a prototype foot/ankle prosthesis. This prototype has been designed and fabricated with the intention of providing decreased ankle joint stiffness during the middle portion of the stance phase of gait, and increased (i.e., more normal) knee range of motion during stance. Our evaluation involved fitting the existing prototype foot/ankle prosthesis, as well as a traditional solid ankle cushioned heel (SACH) foot, to an otherwise healthy volunteer with a below-knee (BK) amputation. We measured this individual's lower extremity joint kinematics and kinetics during walking using a video motion analysis system and force platform. These measurements permitted direct comparison of prosthetic ankle joint stiffness and involved side knee joint motion, as well as prosthetic ankle joint moment and power.

Mathematical models of host plant infection by helper-dependent virus complexes: why are helper viruses always avirulent?

ABSTRACT Interactions between viruses in plants are common, and some viruses depend on such interactions for their survival. Frequently, a virus lacks some essential molecular function that another provides. In "helper-dependent" virus complexes, the helper virus is transmitted independently by a vector, whereas the dependent virus depends on molecular agents associated with the helper virus for transmission by a vector. A general mathematical model was developed of the dynamics of host plant infection by a helper-dependent virus complex. Four categories of host plants were considered: healthy, infected with helper virus alone, infected with dependent virus alone, and infected with both viruses. New planting of the host crop was constrained by a maximum abundance due to limitation of the cropping area. The ratio of infection rate to host loss rate due to infection is proposed as an important epidemiological quantity, A, that can be used as a measure of the mutual adaptation of the virus and host. A number of alternative equilibria of host infection could occur and were determined exclusively by parameter values; it was informative to display their distribution in the parameter plane: (1/A)(helper) versus (1/A)(dependent). A simple analysis of the distribution of the final equilibria illustrated that the dependent virus could affect the survival of the helper virus, so facilitation between the two can be reciprocal. The distribution of the final equilibria also indicated that a well-adapted helper virus increases the opportunity for a dependent virus to evolve and survive, and the model, therefore, explains why infection with a helper virus usually causes no or little damage to plants, whereas infection with a dependent virus or mixed infection with both often causes very severe damage.

Propofol 2% in critically ill patients: effect on lipids

OBJECTIVE

To investigate the concentrations of triglyceride, cholesterol, and high-density lipoprotein during a 50-hr infusion of 2% propofol, starting within 24 hrs of admission to the intensive care unit (ICU).

DESIGN

Prospective, clinical study.

SETTING

ICU, university hospital.

PATIENTS

Thirty adult patients, who were ventilated and expected to be sedated for >2 days, were studied for 50 hrs, beginning at 1800 hrs on the first day of ICU admission.

MEASUREMENTS AND MAIN RESULTS

Triglyceride, cholesterol, and high-density lipoprotein were measured at 2000, 0400, and 0800 hrs. Tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and C-reactive protein were measured at 2000 hrs. Median cholesterol and high-density lipoprotein concentrations were at the low end of the normal range. In seven patients, peak triglyceride concentrations were >3 mmol/L up to a maximum of 4.83 mmol/L. Although there was no statistical difference in lipid concentrations between days 1 and 2, there was an apparent pattern of increasing triglyceride concentrations. There was a correlation between peak triglyceride concentration and total propofol consumption, but there was no correlation between lipids and age, gender, or Acute Physiology and Chronic Health Evaluation II scores. There was a direct correlation between triglyceride and C-reactive protein concentrations, and an inverse correlation between cholesterol and C-reactive protein. Twenty-two patients had evidence of TNF and 11 patients had an IL-6 of >1000 pg/mL, but there was no relationship between concentrations of cytokines and triglycerides in plasma.

CONCLUSIONS

Infusion of 2% propofol to critically ill patients over a 50-hr period does not result in a significant increase in triglyceride concentrations. Mean cholesterol and high-density lipoprotein concentrations were low throughout the study period. There was a significant direct correlation between triglyceride and C-reactive protein and an inverse correlation between cholesterol and C-reactive protein, suggesting that the changes in lipids in critically ill patients may be partly attributable to the acute-phase response.

Valproate-induced limb malformations in mice associated with reduction of intracellular pH

Valproic acid (VPA) is a commonly used antiepileptic agent that recently has been found useful in the treatment of affective disorders and prophylaxis of migraine. VPA induces congenital malformations, especially spina bifida, in the offspring of women treated with this agent during early pregnancy. The mechanism by which VPA induces abnormal development remains unknown despite many studies in experimental animals in which VPA causes malformations similar to those seen in human infants. Because of its chemical structure as a weak organic acid and its capability to induce postaxial forelimb ectrodactyly in C57BL/6 mice, we postulated that VPA acts to perturb limb morphogenesis by reducing embryonic intracellular pH (pHi). We administered VPA, 200 to 400 mg/kg, to C57BL/6 mice on day 9 of gestation. A dose-dependent incidence of postaxial forelimb ectrodactyly was observed. Forelimb bud pHi was estimated by computer-assisted image analysis from the transplacental distribution of 14C-DMO. At the highest doses, 300 and 400 mg/kg, a decrease of pHi of 0.2 to 0.3 pH units was observed uniformly throughout the limb bud 1 h after VPA treatment. None of these changes were seen after treatment with 2-en VPA, a nonteratogenic analog of VPA. Furthermore, the capability of VPA to induce postaxial forelimb ectrodactyly was greatly enhanced by coadministration of agents that inhibit pHi regulatory processes. These data support the hypothesis that VPA-induced postaxial ectrodactyly in murine fetuses can be attributed to reduction in limb bud pHi.

Use of 2% propofol to produce diurnal sedation in critically ill patients

OBJECTIVE

The assessment of propofol to produce diurnal sedation in critically ill patients.

DESIGN

Prospective clinical study.

SETTING

Intensive Care Unit, University Hospital.

PATIENTS AND PARTICIPANTS

Thirty consecutive patients admitted to the Intensive Care Unit older than 18 years who were expected to be sedated for more than 50 h.

INTERVENTIONS

The patients were randomised into two groups. All received sedation with a constant background infusion of morphine and a variable infusion rate of propofol, which was altered hourly to maintain the intended sedation score. The first group received constant light sedation (CLS) over 50 h aiming for a Ramsay score of 2-3. The second group received CLS between 0600 h and 2200 h and additional night sedation (ANS) with propofol between 2200 h and 0600 h, aiming for a sedation score of 4-5.

MEASUREMENTS AND RESULTS

Patients were studied for 50 h from 1800 h on the first day of admission. Recordings of heart rate, blood pressure, sedation scores and propofol and morphine infusion rates were made hourly. An APACHE II score was recorded for each patient. Sedation scores were analysed by blind visual assessment and cosinor analysis, which is used in chronobiology to examine the correlation of data with a cosine curve. Patients in the ANS group had significantly better rhythmicity of sedation levels using cosinor analysis (r = 26% v 8%) p < 0.01. There was no difference between the CLS and ANS groups with respect to age, sex or APACHE II scores. Nine out of 15 patients in the ANS group achieved diurnal sedation. Three patients in the CLS group showed diurnal rhythmicity of sedation, which can be attributed to natural sleep, and had a median APACHE II score of 12. Five patients in the CLS group and three in the ANS group showed a deep constant sedation pattern. They had high APACHE II scores (median 21.5) and an obtunded conscious level on admission due to severe sepsis.

CONCLUSION

Propofol can safely provide diurnal sedation in the critically ill when titrated against the Ramsay score. Sedation levels cannot be manipulated in some severely ill patients.

Estimating intracellular pH in developing rodent embryos using a computer imaging technique: changes in embryonic pH and proliferation rates following maternal treatment with acetazolamide

Using the transplacental distribution of the weak acid 5,5-dimethyloxazolidine-2,4-dione (DMO), a computer assisted imaging technique has been developed to permit the estimation of intracellular pH (pHi) in very specific areas of the developing rodent embryo. The study reported here demonstrates the heterogeneity of radiolabeled DMO distribution in the developing mouse forelimb. The pattern of pHi distribution shifts from one of high pHi values in the proximal core of the mesoderm on day 10 of gestation to one of higher pHi values in the mesoderm just underlying the ectoderm on day 11. Studies [Scott et al. (1990) Toxicol. Appl. Pharmacol. 103:238-254] in which DMO concentration was monitored following treatment with acetazolamide or acetazolamide plus amiloride were done in whole embryo homogenates or pooled limb samples which allow for the calculation of an average pHi but may not reflect the pHi in very specific locations of the limb. Two hours after acetazolamide administration, the pHi pattern was not significantly changed from control. Intracellular pH was raised above control levels but was not significant statistically except in the peripheral mesoderm in the ventral third of the forelimb. Fifteen hours after acetazolamide treatment, there was a significant decrease in pHi values with no change in pattern. However, treatment with acetazolamide plus amiloride for 15 hr produced a marked reduction of pHi values throughout the forelimb bud. Changes in bromodeoxyuridine labeling index (an indication of proliferative activity) following treatment with acetazolamide or acetazolamide plus amiloride are reported. The combination treatment reduced the labeling index by approximately 15% below that of control embryos in the limb region where absence of digit(s) will occur. However, we found no overall correlation of proliferative rate and pHi of limb bud mesoderm in treated embryos. Consequently, we were unable to causally associate reduced pHi with decreased proliferative rate.

Initial management and transport of patients with perforating eye injuries

The first 24 hours are critical for a good surgical result from perforating eye injuries. The basic principles of initial management and transfer include prevention of vomiting, pain and infection, and avoidance of further injury. Where air transport is necessary it must be with the cabin altitude at sea level, or as low as is safe. Surgical repair should be undertaken as promptly as is practical.

A high-field superferric NMR magnet

Strong, extensive magnetic fringe fields are a significant problem with magnetic resonance imaging magnets. This is particularly acute with 4-T, whole-body research magnets. To date this problem has been addressed by restricting an extensive zone around the unshielded magnet or by placing external unsaturated iron shielding around the magnet. This paper describes a solution to this problem which uses superconducting coils closely integrated with fully saturated iron elements. A 4-T, 30-cm-bore prototype, based on this design principle, was built and tested. The 5 G fringe field is contained within 1 meter of the magnet bore along the z axis. Homogeneity of the raw magnetic field is 10 ppm over 30% of the magnet's diameter after passive shimming. Compared with an unshielded magnet, 20% less superconductor is required to generate the magnetic field. Images and spectra are presented to demonstrate the magnet's viability for magnetic resonance imaging and spectroscopy.