Three-dimensional imaging and computational modelling for estimation of wall stresses in arteries.

The paper reviews techniques for the estimation of wall stresses in arterial disease. Wall stresses are important as arterial disease progresses through a complex interplay between local biology and local mechanical stresses. The possibility then arises of using wall stresses as new diagnostic indicators in patients with arterial disease. Estimation of wall stresses using imaging systems is problematic. Developments in the last 10 years have been aimed at providing tools for estimation of wall stresses within individual patients, using a combination of three-dimensional (3D) imaging and computational modelling. For blood flow, 3D arterial lumen information is obtained from 3D imaging. Computational fluid dynamics is then used to estimate the 3D velocity field within the lumen, from which wall shear stress may be calculated. For arterial mechanics, the 3D arterial wall geometry is integrated with solid modelling to provide estimates of the strain field and stress field within the artery wall. For intraplaque stresses, this has been achieved through the use of detailed two-dimensional (2D) intraplaque geometry from MRI. Inverse techniques have been used to provide images of Young's modulus in atherosclerotic plaque using intravascular ultrasound and solid modelling. Several research centres now have processing chains to allow this technology to be used in clinical studies. In time, possibly over the next 10 years or so, robust protocols with proven clinical utility will arise which, when combined with high-performance computing, will allow image-guided modelling to be used as an adjunct to modern radiology in the same way that image-processing tools are used today.

Variability in determination of point of needle insertion in peripheral nerve blocks: a comparison of experienced and inexperienced anaesthetists.

Accurate identification of surface landmarks is essential for the successful performance of peripheral nerve blocks. The variability between experienced and inexperienced practitioners in identifying anatomical landmarks has not been studied previously. Anaesthetists were asked to identify the point of needle insertion for posterior lumbar plexus and sciatic nerve blocks on a volunteer using a standard textbook description. The chosen point for needle insertion was described in terms of X and Y co-ordinates, measured in millimetres, from a zero reference point marked on a volunteer's back. Fifteen experienced and 22 inexperienced anaesthetists took part in the study. The lumbar plexus block mean [range] values for the X, Y co-ordinates were 80 [62-108], 66 [46-86] and 92 [49-150], 62 [0-131] in the experienced and inexperienced groups, respectively. The sciatic nerve block X, Y co-ordinates were 77 [62-99], 70 [49-89] and 68 [29-116], 62 [26-93] in the experienced and inexperienced groups, respectively. The variance for the point of needle insertion was significantly greater in the inexperienced group (p <0.01) for both the lumbar plexus and sciatic nerve blocks. We conclude that with increasing experience, there is decreased variability in determining the point of needle insertion using anatomical landmarks.

Carbon monoxide wash-in method to determine gas transfer in vascular beds: application to rat hindlimb.

The vascular barrier to gas transfer is an important physiological parameter; however, no readily applicable technique exists to quantitate the process. A simple technique to measure the permeability-surface area (PS) product for gas transfer in vascular beds is proposed using wash in of carbon monoxide (CO) and Crone-Renkin analysis. Wash-in experiments were performed on the perfused hindlimbs of male Wistar rats (n = 15) by using CO as a surrogate marker for oxygen and technetium-99m-labeled albumin as the vascular marker. The use of CO and erythrocyte-free perfusate and the collection of outflow samples into tubes preloaded with erythrocytes obviated the need for an anaerobic collection device or consideration of Hb binding in the analysis. The PS product for CO was determined from the early extraction as 0.013 +/- 0.006 ml. s(-1). g(-1). Compartmental analysis revealed that the fractional recovery of CO was 0.45 +/- 0.14 and the volume of distribution was 2.31 +/- 0.76 ml/g. This technique detected a small measurable barrier to the transfer of CO across the hindlimb vasculature and is potentially applicable to other vascular beds in health and disease.

Computed tomography in the diagnosis of equivocal appendicitis.

BACKGROUND: The clinically obscure right iliac fossa (RIF) pain remains a diagnostic problem. The present study examines the use of computed tomography (CT) in improving the accuracy of clinical assessment in these difficult surgical cases. METHODS: The trial design was a retrospective review of all patients admitted under one surgeon with suspected acute appendicitis, between 1 January 1995 and 30 June 1997. The study setting was a district hospital (Calvary Hospital) that received patients from both an urban and rural environment. The patient cohort was identified from the Unit Registry and an International Classification of Diseases-based review of medical records. Twenty-one prospective data points were obtained from patient records. Those patients admitted with RIF pain and equivocal symptoms and signs subsequently underwent a CT and/or ultrasound (US) examination, conducted by the attending radiologist. For those patients who proceeded to appendicectomy, the histopathological findings were correlated with the imaging report. Those patients who were discharged after imaging without proceeding to operation were not readmitted to any regional hospital during the course of the study. RESULTS: A total of 84 patients were identified. Thirty-three patients (39%) underwent appendicectomy without imaging and were excluded from further analysis. A total of 51 patients (61%) underwent 61 imaging procedures. The CT scan was correct in 35/36 patients (97%), while US was correct in 17/25 patients (68%). CONCLUSIONS: The present study suggests that CT can be used to improve the accuracy of diagnosis of obscure RIF pain. As a pilot study, it supports the development of a randomized controlled trial in a multicentre regional study.

Effect of oxidized lipids in the diet on oxidized lipid levels in postprandial serum chylomicrons of diabetic patients.

OBJECTIVE: To determine whether humans with type 2 diabetes have increased levels of oxidized fatty acids in their serum chylomicron fraction after the ingestion of dietary oxidized fatty acids. RESEARCH DESIGN AND METHODS: The study was performed on 31 male type 2 diabetic patients and 24 age-matched control subjects. Among the diabetic patients, 22 had poor glycemic control, defined as HbA1 > 10% (normal value < 7.7%). Nine patients had good glycemic control (HbA1 < or = 10). Heated corn oil containing low or high levels of oxidized fatty acids was used as a test meal. At 2.5 h after the test meal, 50-ml blood samples were obtained from all subjects, and the chylomicron fraction (Sf > 1,000) was isolated. The degree of oxidation in chylomicrons was determined by measuring conjugated dienes. For determining the postprandial levels of triglycerides and of oxidized lipids in serum chylomicrons over an extended time period, blood samples were obtained at 0, 2.5, 5.0, and 7.5 h for isolation of chylomicrons and determination of fatty acid oxidation. RESULTS: We found that at 2.5 h after the consumption of the test meal containing either a low or high oxidized fatty acid content, conjugated dienes in serum chylomicrons in diabetic subjects in poor glycemic control were increased compared with those in control subjects. Diabetic patients in good glycemic control had similar levels of oxidized lipid in their chylomicrons when compared with control subjects. Additionally, in diabetic patients in poor glycemic control, the levels of oxidized lipids in chylomicrons remained elevated for an extended post-prandial period. CONCLUSIONS: In diabetic subjects with poor glycemic control, dietary oxidized lipids induce an exaggerated and sustained increase in the levels of oxidized lipids in chylomicrons when compared with either control subjects or diabetic patients with good glycemic control. These increased postprandial levels of potentially atherogenic oxidized lipids may contribute to the accelerated atherosclerosis associated with diabetes.

In situ measurements of skeletal muscle power output using new capacitive strain gauge.

Experiments are described in which a fatigue index is determined for the latissimus dorsi muscle of sheep in situ, using capacitive strain gauges. Parallel experiments for invasive and non-invasive measurements are conducted, measuring global contraction and relaxation rates and shortening duration for paced muscle. The results show that, above one pulse per burst (5 V, 100 microseconds pulsewidth), contraction rates (62 +/- 11 mm s-1) and relaxation rates (50 +/- 7 mm s-1) are constant for unloaded muscle. For one animal, fatigue testing with a 2.5 kg load at six pulses per burst shows shortening rates increasing to a maximum (80 mm s-1) after 30 s and reducing to 5 mm s-1 after 150 s. The decrease in shortening amplitude is used as a fatigue index, log displacement against time. Power output is load dependent, measuring 4.7 W kg-1 with a 2.5 kg load. There is good agreement between the invasive and non-invasive measurements, thus providing a method for monitoring changes in muscle parameters non-invasively during future pacing transformation.

Aortic reconstructive surgery for limb ischaemia: immediate and long-term follow-up to provide a standard for endovascular procedures.

PURPOSE: Aortobifemoral and aortobiliac bypass has been a preferred treatment of severe aortoiliac occlusive disease. Recently, endovascular procedures and unilateral bypass grafting have been introduced. We report the results of aortic reconstructive surgery over a 19-year period (1975-1994). METHODS: A total of 285 patients underwent surgery. Follow-up data from clinical notes, general practitioner questionnaire or phone interview was available in 93.3% (266/285). RESULTS: Of the total 68% were male (180/226) and the median age was 63 years (range 22-85 years). Indications for surgery were tissue loss/gangrene (n = 32), rest pain (n = 84), severe claudication (n = 40), moderate claudication (n = 110). Total of 177 bifurcated grafts, 51 iliofemoral, eight left/right aortofemoral, and 30 other procedures were performed. The median duration of follow-up was 49.8 months. Cumulative secondary graft patency for 2, 5 and 10 years was 97.7%, 95.9%, and 94.4%. The amputation rate was 4.5% (12/266). Early mortality occurred in eight of 266 patients (3%) and late mortality in 60 patients. The most common cause of late death was ischaemic heart disease (24/60 followed by cancer (14/60). Data was further analysed by type of graft, risk factors, complications and previous and subsequent surgery. In our experience, aortic reconstructive surgery is a successful option for the management of severe aortoiliac occlusive disease. The outcome of other methods of maintaining arterial patency should be measured against this standard.

Biochemical characterization of a haloalcohol dehalogenase from Arthrobacter erithii H10a.

Arthrobacter erithii H10a possesses two enzymes capable of catalyzing the dehalogenation of vicinal halohydrins which have been designated as dehalogenases DehA and DehC. The DehA dehalogenase demonstrated greater activity toward 1,3-dichloro-2-propanol (1,3-DCP) while the DehC dehalogenase showed higher activity toward 3-chloro-1,2-propanediol (3-CPD) and brominated alcohols. The DehA dehalogenase was composed of two non-identical subunits (relative molecular mass of 31.5 and 34 kDa) which probably associate with other proteins to form a large catalytically active protein of 200 kDa. The two subunits were purified and the amino acid sequence of their tryptic digests determined. The DehA enzyme catalyzed the conversion of vicinal halohydrins to epoxides and the reverse reaction in the presence of an excess of halogen. This enzyme had maximum activity at 50 degrees C and a broad pH optimum over the range 8.5-10.5. The apparent K(m) and Vmax values for dehalogenation of 1,3-DCP and 3-CPD were 0.105 mM and 223 mumol min-1 mg-1; and 2.366 mM and 1.742 mumol min-1 mg-1, respectively. The enzyme was inhibited by 2-chloroacetic acid (MCA) and 2,2-dichloroacetic acid (DCA). The inhibition pattern suggested a mixed type inhibition which was predominantly uncompetitive. Amino acid modification experiments demonstrated that one or more cysteine and arginine residues are likely to be involved in catalysis or play an important role in the maintenance of the enzyme structure. The characteristics of the DehA enzyme are compared to those of previously reported haloalcohol dehalogenases and discussed in terms of diversity of this type of dehalogenase.

Some biochemical properties and the classification of a range of bacterial haloalkane dehalogenases.

Multivariate analyses and experimental data have been used to evaluate the relationships between eight bacterial hydrolytic haloalkane dehalogenases. The results indicate that seven of the dehalogenases investigated can confidently be placed into two Classes [sensu Slater, Bull and Hardman (1995) Biodegradation 6, 181-189] according to their substrate profiles. The remaining enzyme, isolated from Rhodococcus erythropolis CP9, appears to represent a third Class of haloalkane dehalogenases.

Teaching normal physical examination in a large-group interactive using artists' models.

BACKGROUND: The innovative use of artists' models within the context of a large-group interactive teaching session, at Royal North Shore Hospital is reviewed. METHODS: The models were used to teach normal physical examination skills to a group of junior medical students, during their surgical rotation. This same group of students were also exposed to traditional bedside tutorials. The students evaluated both teaching experiences. RESULTS: In the four areas of evaluation (interaction, explanation, presentation, and organization), the large-group interactive sessions were consistently rated higher than the bedside tutorial (P < 0.001). CONCLUSIONS: The teaching technique is presented as an effective way of delivering quality clinical training to a group of junior medical students in an environment where access to good teaching material is becoming increasingly difficult.

Exposure to cigarette smoke delays the plasma clearance of chylomicrons and chylomicron remnants in rats.

We investigated the effects of cigarette smoke exposure on the clearance of chylomicrons (CM) and CM remnants in rats after administration of a fat-containing meal. There was a decrease in clearance of both postprandial CM and exogenous radiolabeled CM in smoke-exposed animals. For exogenous CM, clearance (t1/2) increased significantly for both triglyceride and cholesterol labels and correlated with the delay in liver uptake. This decrease in lipid clearance could not be explained by decreased lipoprotein lipase (LPL) activity because smoke exposure resulted in a significant increase in LPL activity. When the hydrolysis of CM by endothelial LPL was tested in a heart perfusion system, there was no difference in CM hydrolysis between the two groups. Hepatic lipase activity was also unchanged in smoke-exposed animals. However, there was a significant delay in the CM remnant uptake into livers isolated from smoke-exposed rats. Thus the delay in CM clearance in smoke-exposed animals cannot be attributed to reduced lipase activities but results from impaired hepatic uptake of CM remnants.

A single copy of apolipoprotein B-48 is present on the human chylomicron remnant.

Individuals homozygous for the e2 allele encoding apolipoprotein E exhibit a remnant removal defect and accumulate substantial levels of intestinally derived particles containing apolipoprotein B-48 (apoB-48). Such lipoproteins were isolated from the plasma of E2/E2 individuals, and further purified by affinity chromatography using a polyclonal antibody specific for selective binding and removal of apoB-100-containing lipoproteins. The unbound lipoproteins, termed chylomicron remnants, were particles with average hydrated diameters of 31.2 nm as determined by dynamic light scattering. They contained apoB-48 and ApoE as their only protein components. The number of apoB-48 molecules on each lipoprotein was assessed by counting the number of antibody molecules bound to the surface of the chylomicron remnants, using either a monoclonal antibody specific for a single epitope on apoB-48 or a mixture of two such monoclonal antibodies specific for widely separated epitopes. The results of this analysis seem unambiguous: no more than one apoB-48 resides on the chylomicron remnant. Because apoB appears to be unable to transfer among lipoprotein particles, it may be inferred that nascent chylomicrons also contain a single copy of apoB-48.

Limitations of intra-arterial thrombolysis.

The purpose of this study was to assess the efficacy, costs and complications of acutely ischaemic limbs initially treated with urokinase-induced thrombolysis, and to compare the subsequent patencies of occluded native arteries, vein grafts and prosthetic grafts. Data from 45 consecutive episodes of thrombolysis in 37 patients (37 limbs) were reviewed retrospectively. An initial bolus dose of urokinase was used in all limbs, with pulse-spray in nine 30 limbs received additional infusions of urokinase including six who received initial treatment with pulse-spray. Percutaneous transluminal angioplasty or surgical intervention was undertaken at any stage when considered appropriate. There were 14 occluded native arteries (31%), 12 vein grafts (27%), 16 prosthetic polytetrafluoroethylene grafts (35%), and three composite grafts (7%). Thrombolysis was initially successful in 33 episodes (73%). Of these, no additional procedure was required in three, percutaneous transluminal angioplasty in 23, other surgery in 11 and bypass surgery in seven with more than one additional procedure being undertaken in 10. Of the 12 episodes with initial failure, major surgery was performed in eight and no procedure in four. Lysis-related complications occurred in 19 treatment episodes (42%) with major bleeding in seven (16%), minor bleeding in 10 (22%), distal embolization in 11 (24%) and arterial dissection in two (4%). One amputation (2%) and one death (2%), both directly attributable to thrombolysis, occurred within 1 month of treatment. Complications occurred in 10 of 19 (53%) prosthetic or composite grafts, five of 12 (42%) vein grafts, and four of 14 (29%) native artery occlusions (P = 0.38). The median follow-up of patients remaining alive was 24 months. The overall mean (s.e.m.)patency rate at 6 months of lysed vessels or replacement bypass grafts was 44% (8%). Presentation with a native artery and or graft occlusion was associated with superior long-term patency (any subsequent conduit) compared with presentation with an occluded prosthetic graft (log rank chi2[1] = 7.00, P = 0.008) and reflects the inferior run-off of the latter patients. The average cost of thrombolysis in radiological procedures and disposables alone excluding intensive care and complications was AUD$2440.

Biodehalogenation of low concentrations of 1,3-dichloropropanol by mono- and mixed cultures of bacteria.

The degradation of low concentrations of 1,3-dichloro-2-propanol (1,3-DCP) and related halohydrins by whole cells and cell-free extracts of soil bacteria has been investigated. Three bacteria (strains A1, A2, A4), isolated from the same soil sample, were distinguished on the basis of cell morphology, growth kinetics and haloalcohol dehalogenase profiles. Strain A1, probably an Agrobacterium sp., dehalogenated 1,3-DCP with the highest specific activity (0.33 U mg protein-1) and also had the highest affinity for 1,3-DCP (Km, 0.1 mM). Non-growing cells of this bacterium dehalogenated low concentrations of 1,3-DCP with a first-order rate constant (kl) of 1.13 h-1. The presence of a non-dehalogenating bacterium, strain G1 (tentatively identified as Pseudomonas mesophilius), did not enhance the dehalogenation rate of low 1,3-DCP concentrations. However, the mixed-species consortium of strains A1 and G1 had greater stability than the mono-species culture at DCP concentrations above 1.0 gl-1.

Lack of the t(2;5) or other mutations resulting in expression of anaplastic lymphoma kinase catalytic domain in CD30+ primary cutaneous lymphoproliferative disorders and Hodgkin's disease.

The t(2;5) (p23;q35) chromosomal translocation has been found in a high proportion of lymph node-based CD30+ large cell lymphomas of T-cell lineage. This translocation is believed to result in the expression of a fusion protein containing the catalytic domain of anaplastic lymphoma kinase (ALK) under the control of the promoter for nucleophosmin, a nucleolar phosphoprotein. Expression of ALK activity, which does not normally occur in lymphocytes, is postulated to be involved in the pathogenesis of lymphomas bearing the t(2;5) translocation. Several primary cutaneous lymphoproliferative disorders and Hodgkin's disease are also known to contain CD30+ large lymphoid cells. To determine the role of the t(2;5) translocation in these diseases, we developed a DNA-based polymerase chain reaction (PCR)/Southern blot assay to detect this translocation at the genomic level in lymphomatoid papulosis (14 cases), primary cutaneous CD30+ large cell lymphoma of T-lineage (10 cases) and Hodgkin's disease (13 cases). Two cases of pityriasis lichenoides were also studied. The t(2;5) translocation was not present in any of these specimens. To determine if some other somatic mutation might have resulted in inappropriate expression of ALK catalytic domain, we devised an RNA-based reverse transcriptase-PCR assay to detect transcripts encoded by this ALK region. None were found in the six additional cases of lymphomatoid papulosis that were studied. In aggregate, these results strongly suggest that inappropriate expression of ALK is not involved in the pathogenesis of these CD30+ lymphoproliferative disorders, and that lymph node-based CD30+ large cell lymphoma is a disease that is biologically distinct from skin-based CD30+ lymphoproliferative disorders and Hodgkin's disease. Using methods developed for this report, we also cloned and sequenced the t(2;5) genomic junctional sequences present in the SUP-M2 and SU-DHL-1 cell lines. These intron sequences will be useful for mapping t(2;5) breakpoint clusters.