Management of parapharyngeal space cavernous sinus haemangioma using transoral robotic surgery.

Cavernous haemangiomas are a very rare occurrence in the parapharyngeal space (PPS). Here, we present a case of a 58-year-old woman with an incidentally identified left PPS mass thought to be a pleomorphic adenoma that underwent excision by transoral robotic surgery (TORS). Intraoperative findings demonstrated no solid mass present and histological assessment of resected tissue confirmed a cavernous haemangioma. We discuss our experience in the management of a radiological and surgical mismatch of a PPS mass in what we believe to be the first cavernous haemangioma to be excised by TORS in this region.

QTL and association analysis for skin and fibre pigmentation in sheep provides evidence of a major causative mutation and epistatic effects.

The pursuits of white features and white fleeces free of pigmented fibre have been important selection objectives for many sheep breeds. The cause and inheritance of non-white colour patterns in sheep has been studied since the early 19th century. Discovery of genetic causes, especially those which predispose pigmentation in white sheep, may lead to more accurate selection tools for improved apparel wool. This article describes an extended QTL study for 13 skin and fibre pigmentation traits in sheep. A total of 19 highly significant, 10 significant and seven suggestive QTL were identified in a QTL mapping experiment using an Awassi × Merino × Merino backcross sheep population. All QTL on chromosome 2 exceeded a LOD score of greater than 4 (range 4.4-30.1), giving very strong support for a major gene for pigmentation on this chromosome. Evidence of epistatic interactions was found for QTL for four traits on chromosomes 2 and 19. The ovine TYRP1 gene on OAR 2 was sequenced as a strong positional candidate gene. A highly significant association (P < 0.01) of grandparental haplotypes across nine segregating SNP/microsatellite markers including one non-synonymous SNP with pigmentation traits could be shown. Up to 47% of the observed variation in pigmentation was accounted for by models using TYRP1 haplotypes and 83% for models with interactions between two QTL probabilities, offering scope for marker-assisted selection for these traits.

Communication in and clinician satisfaction with multidisciplinary team meetings in neuro-oncology.

Multidisciplinary Team (MDT) meetings are critical in the management of complex cancer cases. There are limited data regarding the effectiveness of neuro-oncology MDT meetings and the impact of documenting and disseminating the recommended patient management. We established a weekly neuro-oncology MDT meeting and developed a standard electronic communication process. A survey was issued to participating clinicians to assess their level of satisfaction. The survey revealed that 100% felt the meeting and its documentation was very or extremely important, and 94% (n=15) felt the meeting was effective in documentation and communication of plans. There was a mixed response regarding which patients should be discussed: 44% (n=7) thought all patients should be discussed and 56% (n=9) thought only those patients with complex management issues should be discussed. We have developed an efficient method of documenting and disseminating patient information arising from our neuro-oncology MDT meeting. Clinician satisfaction was high.

Protein catabolism in advanced renal disease: role of cytokines.

BACKGROUND: Protein energy wasting is a maladaptive metabolic state often associated with inflammation, which is common in patients with chronic kidney disease (CKD). METHODS: A literature search was performed using MEDLINE and the reference lists of relevant review articles. The following key words were used in the MEDLINE search: "cytokines", "inflammation", "protein metabolism", "acute-phase protein", "cachexia", "chronic kidney disease", "end-stage renal disease" and "hemodialysis". The search was limited to English-language articles. RESULTS: While experimental models have shown that uremic animals are more prone for proteolysis, the results from the human studies are controversial. Intradialytic loss of amino acids and activation of proinflammatory cytokines lead to protein catabolism during hemodialysis (HD). At the whole-body level, intradialytic parenteral nutrition (IDPN) increases protein synthesis and decreases proteolysis. Amino acid infusion during HD increases muscle protein synthesis, but does not decrease protein catabolism. Activation of interleukin-6 during HD induces protein catabolism, impairs amino acid utilization for protein synthesis and increases acute-phase protein synthesis. CONCLUSION: The changes in albumin, fibrinogen and muscle protein kinetics during HD could be due to competing and complementary effects of availability of amino acids and activation of proinflammatory cytokines.

Cigarette smoke inhibits macrophage sensing of Gram-negative bacteria and lipopolysaccharide: relative roles of nicotine and oxidant stress.

BACKGROUND AND PURPOSE: Smoking cigarettes is a major risk factor for the development of cardiovascular and respiratory disease. Moreover, smokers are more prone to infections. This has been associated with a suppression of the immune system by smoke. However, it is not clear how cigarette smoke affects the ability of immune cells to sense pathogens. Cigarette smoke contains a large number of molecules which may mediate responses on immune cells and of these, nicotine and oxidants have both been identified as inhibitory for the sensing of bacterial lipopolysaccharide (LPS). Nitric oxide synthase (NOS) and tumour necrosis factor (TNF)-alpha are both induced in macrophages on stimulation with Gram negative bacteria or LPS. EXPERIMENTAL APPROACH: We used murine macrophages stimulated with whole heat-killed bacteria or LPS. We measured output of NO (as nitrite) and TNFalpha, NOS protein by Western blotting and cellular oxidant stress. KEY RESULTS: Cigarette smoke extract suppressed the ability of murine macrophages to release NO, but not TNFalpha in response to whole bacteria. Cigarette smoke extract also inhibited nitric oxide synthase II protein expression in response to LPS. The effects of cigarette smoke extract on nitrite formation stimulated by LPS were unaffected by inhibition of nicotinic receptors with alpha-bungarotoxin (100 units ml(-1)). However, the effects of cigarette smoke extract on LPS-induced nitrite formation were mimicked by hydrogen peroxide and reversed by the anti-oxidants N-acetyl cysteine and glutathione. CONCLUSIONS AND IMPLICATIONS: We suggest that cigarette smoke exerts its immunosuppressive effects through an oxidant-dependent and not a nicotine-dependent mechanism.

Cullen's sign and massive ovarian enlargement secondary to primary hypothyroidism in a patient with a normal FSH receptor.

Ovarian hyperstimulation is a recognised complication of longstanding hypothyroidism. A 12 year old girl with atrophic thyroiditis who presented with abdominal pain and distension is reported. She was noted to have bruising in the vicinity of the umbilicus (Cullen's sign). She had pronounced ovarian enlargement on ultrasonography and it was hypothesised that this profound phenotype might reflect an abnormal FSH receptor. However sequencing of the FSH receptor was normal. The ovarian enlargement resolved with thyroxine replacement. Physicians and surgeons should consider longstanding hypothyroidism in patients presenting with Cullen's sign.

Repeat survey of current practice regarding corticosteroid prophylaxis for patients at increased risk of adverse reaction to intravascular contrast agents.

AIM: To compare the findings of a survey undertaken by us in 2002 regarding steroid premedication given in radiology departments to reduce the risk of adverse reactions in patients at increased risk of intravascular contrast media reactions with a similar survey published in 1994 by R. Seymour et al. The high risk patients considered in our survey were patients with history of asthma, drug allergies, hay fever and eczema. MATERIALS AND METHODS: A total of 225 questionnaires were sent to the consultant in charge for audit for radiology departments from the list given by the Royal College of Radiologists. 175 of the 225 questionnaires were returned (response rate 77.8%) and of these 172 were analysed with respect to the type, dose and duration of steroids. RESULTS: Compared to the survey in 1994, it was found that the number of departments who use steroid cover for all category of risk factors had increased compared to previous survey (73.8% in 2002 versus 55.3% in 1994 (p=0.001). There is now almost universal use of non-ionic contrast 98.8% versus 82.4% in 1994 (p=0.001). There is no agreed policy among radiology departments for the need or the dose or duration of steroid cover. CONCLUSION: Despite the more widespread use of non-ionic contrast media, the use of steroid premedication has increased which is contrary to what is expected as the incidence of adverse reaction to non ionic media is less than ionic contrast media.

Electronic structure investigation of Mg(1-x)Fe(x)S solid solution: X-ray absorption study.

X-ray absorption fine structure at the sulfur K edge in Mg(1-x)Fe(x)S solid solution (0 < or = x < or = 0.68) has been measured at the Canadian Synchrotron Radiation Facility. It was shown that the S K-edge in MgS was formed by the multiple scattering of the photoelectron wave within a cluster of large size (containing 27 atoms and having radius about 4.5 A). Comparison of experimental data with theoretical results allows study of the electronic structure of this system. The analysis of partial electronic density of s-, p- and d- states makes it possible to investigate the mutual influence of sulfur s-, p- and metal d- states in the conduction band. The study of changes in experimental S K-edges XANES of Mg(1-x)Fe(x)S solid solution with variation of relative Fe-Mg concentration allows the extraction of the hypothetical cubic phase (B1) of FeS, and this is supported by theoretical simulation.

Intestinal atresia with gastroschisis: a selective approach to management.

BACKGROUND: The association of bowel atresia with gastroschisis is well recognized, but the ideal management is less certain. METHODS: The records of 10 infants with gastroschisis and intestinal atresia treated between 1991 and 1997 in a single neonatal surgical unit were reviewed. RESULTS: Ten infants had midgut atresias: 5 small intestine, 1 jejunum and colon, and 4 colonic. Of the 6 with small bowel atresias, 4 had primary abdominal wall repair with electively delayed primary anastomosis at 21 to 46 days, 1 had decompressing tube jejunostomy at 11 days at the time of secondary abdominal closure, and 1 initial jejunostomy. Of the 4 with colonic atresia alone, 3 had perforation or infarction of the proximal colon at birth, 2 had a primary stoma, and 2, who did not have initial colostomy or anastomosis, required reoperation for increasing abdominal distension at 11 and 23 days. Complications were recorded in 6 patients: 2 had necrotizing enterocolitis after which 1 developed malabsorption, 1 had distal bowel obstruction after delayed primary anastomosis treated with a Bishop-Koop ileostomy at 50 days, 2 had stoma stenosis, and 1 had stoma prolapse. None died, and at 1 year 9 were within the normal range for body weight, and details of 1 are not known. CONCLUSIONS: At birth, diagnosis of atresia often is uncertain, and the bowel is difficult to repair or exteriorize. For proximal atresias, delayed primary repair is a safe satisfactory approach. At birth, distal atresias are more obvious, often complicated by perforation or infarction, and may benefit from early enterostomy.

Percutaneous fibrin sleeve stripping of failing haemodialysis catheters.

BACKGROUND: One of the most frequent reasons for failure of haemodialysis lines is catheter blockage caused by fibrin sheath formation. We report our experience of percutaneous fibrin sheath stripping in treating this problem. METHODS: A consecutive series of failing haemodialysis catheters underwent percutaneous fibrin sheath stripping in an attempt to retrieve and prolong the life of the catheter. Immediate technical success, clinical success, and primary and secondary patency were measured based on clinical follow-up. RESULTS: Sixteen non-functional permanent haemodialysis lines in 15 patients underwent percutaneous fibrin sheath stripping on 21 occasions. Technical success rate was 100%. Catheter flow rates sufficient for initial dialysis were achieved in 12 (75%) lines. Successful percutaneous fibrin sheath stripping produced a mean catheter patency of 126 days (range 6-299 days). CONCLUSIONS: Percutaneous fibrin sheath stripping is a simple, repeatable procedure that can usefully extend the life of a failing dialysis line. However, a randomized trial will be needed to evaluate its role compared with catheter replacement.

A comparison of two or three radiographic views in the diagnosis of skull fractures.

The aim of the study is to determine whether a two rather than a three-view skull series is adequate for diagnosis of a skull fracture given a reliable history of the site of trauma. The radiographs of 50 patients who were diagnosed and managed as having sustained skull fractures were randomly mixed with 200 normal skull series and viewed independently by three observers. For all the film series viewed (a total of 1500 for the three observers), the diagnostic confidence level for two films was 94.4%, and for three films 94.6%. Of a total of 150 skull fracture series viewed as two films, 87 (58%) were correctly diagnosed with a confidence level of 92.7%. When viewed as three films, 92 (61.3%) were correctly diagnosed with a confidence level of 93%. Combined with analysis of false-positive and false-negative results, no statistical difference could be detected between a two or three film skull series. A two-view skull series has no statistically deleterious effect on either diagnostic accuracy or confidence of interpretation when compared with a three-view series given an accurate clinical history.

Subclavian artery injury following percutaneous insertion of dialysis catheter.

Iatrogenic subclavian artery injury is a rare but recognized complication of central venous catheterization. The lesion is more severe and complex to treat when produced by large catheters such as dialysis catheters. A case is presented below with a discussion of vascular access for renal replacement therapy and the principles of treating penetrating arterial trauma at this location.

A genetic selection for isolating cDNAs encoding secreted proteins.

We describe a simple, rapid technique for simultaneously isolating large numbers of cDNAs encoding secreted proteins. The technique makes use of a facile genetic selection performed in a strain of Saccharomyces cerevisiae deleted for its endogenous invertase gene. A cDNA cloning vector which carries a modified invertase gene lacking its leader sequence is used in conjunction with this strain. Heterologous secreted genes fused appropriately upstream of this defective invertase provide the necessary signals to restore secretion, allowing the yeast to grow on sugars such as sucrose or raffinose. This microbial growth selection facilitates scanning cDNA libraries containing millions of clones, enabling the wholesale identification of novel secreted proteins without the need for specific bioassays. The technique is similar to one previously described (Klein et al. (1996) Proc. Natl. Acad. Sci. USA 93, 7108-7113). We describe results using a cDNA library derived from activated human peripheral blood mononuclear cells (PBMC). Genes identified from this library encoded signal sequences of proteins of diverse structure, function, and cellular location such as cytokines, type 1 and type 2 transmembrane proteins, and proteins found in intracellular organelles. In addition, a number of novel secreted proteins were identified, including a chemokine and a novel G-protein-coupled receptor. Since signal sequences possess features conserved throughout evolution, the procedure can be used to isolate genes encoding secreted proteins from both eukaryotes and prokaryotes.

Differing effects of two-week suspension on male and female mouse bone metabolism.

The effects of suspension on bone histomorphometry during the first and second week of tail suspension are compared for male and female mice of the common inbred strain, the C57BL/6J. In male mice, significant changes in bone formation rate (BFR) were largely confined to the endocortical perimeter. BFR along the endocortical mid-diaphysis in the femora of suspended male mice was reduced 54.1% and 55.6% for the first and second week, respectively. In female mice, however, measured metabolic changes due to suspension occurred along the periosteal perimeter, where there was a decrease in BFR of 58.3% for the first week and 60.9% for the second. The notable difference in the bone perimeter affected by suspension observed in male and female mice indicates a difference in the metabolic control of bone development in male and female C57BL/6J mice. More importantly, this may indicate a sex-based difference in preserving structural properties in the response of the skeleton to unloading.