Single Centre Experience - Clinical Presentation and Frequency of Paediatric Diabetic Ketoacidosis (DKA) At Diagnosis over a 5-Year Period.

Type 1 diabetes (T1D) symptoms are subtle and easily overlooked. Delayed diagnosis can result in Diabetic ketoacidosis (DKA), a life threatening complication with lasting consequences. We sought to define the presenting features of T1D and DKA frequency, in children <15 years diagnosed in a single national tertiary centre, and identify predictive factors for DKA. A review of T1D incident cases was undertaken from 2008-2012 using the National Diabetes Register (ICDNR) and clinical case notes. Data were compared with a 1997/8 national study. We found DKA at presentation in 28.7 % of children and 15.5% had moderate/severe DKA. Commonest symptoms were polydipsia, polyuria, weight loss, and lethargy. Median symptom duration was 17 days. Clinical presentation was similar and frequency of DKA at T1D diagnosis remains high. The proportion with moderate/severe DKA is lower than the 25% previously reported (p=0.038). National monitoring and targeted action to reduce DKA at diagnosis is required.

Evaluation of thermal therapy in a prostate cancer model using a wet electrode radiofrequency probe.

PURPOSE: To determine the temperature-time threshold of local cell death in vivo for thermal therapy in a prostate cancer animal model and to use this value as a benchmark to quantify global tissue injury. MATERIALS AND METHODS: Two studies were designed in the Dunning AT-1 rat prostate tumor hind limb model. For both studies, a wet electrode radiofrequency (RF) probe was used to deliver 40 W of energy for 18 to 62 seconds after a 30-second infusion of hypertonic saline/Hypaque through the RF antenna. Thermal history measurements were obtained in tumors from at least two Fluoroptic probes placed radially 5 mm from the axis of a RF probe and 10 mm below the surface of the tissue. In study 1, the thermal history required for irreversible cell injury was experimentally determined by comparing the predicted injury accumulation (omega) with cell viability at the fluoroptic probe locations using an in vivo-in vitro assay. The omega value was calculated from the measured thermal histories using an Arrhenius damage model. In study 2, RF energy was applied for 40 seconds in all cases. At 1, 3, and 7 days after thermal therapy, triphenyltetrazolium chloride dye (TTC) and histologic analyses were performed to assess global tissue injury within a 5-mm radius from the axis of the RF probe. RESULTS: Study 1 showed that cell survival dropped to 0 for 0.42 < omega < 0.7. This result was the basis for selection of 40 seconds of RF thermal therapy in study 2, which yielded omegaave = 0.5 in the tissue 5 mm from the probe axis. Both TTC and histology analysis showed that sham-treated tissue was not irreversibly injured. However, there was an inherent heterogeneity present in the tumor that accounted for as much as 15% necrosis in control or sham-treated tissue. In contrast, at 1, 3, and 7 days after therapy, significantly less enzyme activity was observed by TCC in thermally treated tissue compared with sham-treated tissue (35 v 85%; P < 0.001). Histologic analysis of thermally treated tissues revealed a gradual increase in the percent of coagulative necrosis (47%-70%) with a concomitant decrease in the percentage of shocked cells (53%-28%). At day 7, <3% viability was observed in treated tumors compared with 90% viability in sham-treated tissue. CONCLUSION: The threshold of cellular injury in vivo corresponded to omega > 0.7 (> or =48 degrees C for 40 seconds). Global tissue injury could be conservatively predicted on the basis of local thermal histories during therapy.

Radiofrequency ablation of rabbit kidney using liquid electrode: acute and chronic observations.

BACKGROUND AND PURPOSE: The percentage of small renal tumors being diagnosed has increased at least five-fold in the last 20 years. The question of how best to treat these lesions remains unanswered. We studied the effectiveness of "wet" radiofrequency (RF) ablation of renal tissue. MATERIALS AND METHODS: New Zealand white rabbits (N = 48) underwent a 1- or 2-minute ablation of renal parenchyma with a modified insulated spinal needle capable of infusing saline, measuring temperature and impedance, and delivering RF energy. Animals were followed and examined up to 54 days after surgery. RESULTS: All animals survived for the planned period. Intravenous urograms showed no fistula or urinoma formation and confirmed continued function of the remaining parenchyma. The 1-minute treatments consistently ablated 20% to 25% (average 7 cm) of the tissue, whereas the 2-minute treatments ablated 34% to 36% (average 10 cm). Acutely, there was coagulative necrosis and infiltration of inflammatory cells. Chronically, there were well-demarcated lesions with complete effacement of the tubular epithelium and destruction of the glomeruli. CONCLUSION: Wet radiofrequency ablation with a liquid electrode can reproducibly create large lesions safely and quickly. The technique may soon become an alternative, minimally invasive therapy for small renal tumors.

Pressure measurements during injection of corticosteroids: in vivo studies.

Intralesional injection of corticosteroids is an effective treatment for capillary hemangiomas. Complications include embolisation of corticosteroid particles into the ocular circulation resulting in permanent loss of vision. This research is aimed at developing an injection cannula and monitoring system to prevent such inadvertent embolisation. A cannula has been designed to simultaneously estimate the pressure at its tip and the flow rate during injection. The estimation technique has previously been validated using an in vitro model. In this study, the cannula was tested in vivo with canine liver at injection flow rates of 2.5 to 21 ml min-1. The pressure generated in the tissue during injection was calculated using the technique developed. This was compared with direct in situ pressure measurements made with a coaxial outer cannula. The mean calculated pressure was seen to be linearly related to the mean measured pressure with a slope of 0.97, correlation coefficient of 0.99 and standard error of 2.74 mmHg. Similar trends were observed between the maximum calculated and maximum measured injection pressure: slope = 1.0, r = 0.99 and standard error = 5.54 mmHg. The estimation of the mean and maximum pressure from the cannula and monitoring system was accurate in canine liver. High pressures close to 250 mmHg were generated in tissues during injection.

Transurethral prostate ablation using saline-liquid electrode introduced via flexible cystoscope.

An interstitial saline-electrode has been developed to couple radiofrequency (RF) energy to prostate tissue in order to produce large lesions quickly and controllably. In this study, we attempted to produce similar results using a flexible catheter introduced transurethrally via a flexible cystoscope. An insulated 4F catheter with an extendable needle electrode (26-gauge, 5-mm exposed metal tip) was introduced through a port of a flexible cystoscope into the urethra of 10 dogs via a small perineal incision (required for the canine U-shaped urethra). Under visual endoscopic guidance, the electrode was placed in the center of the prostate and the needle electrode extended at an angle into the prostate, one lobe at a time. Hypertonic saline (14.6% NaCl) was infused at 2 mL/min through the needle electrode into the tissue for 30 seconds before and during RF application. The energy (50 W, 475 kHz) was delivered for 30, 45, 60, or 90 seconds (RFT System; U.S. Surgical Corporation). Prostate and urethral temperatures were monitored using thermocouples mounted on the catheter. There was an automatic high-temperature shut-off if the urethra reached >42 degrees C or if impedance reached >300 omega during RF energy application. Prostate sizes ranged from 1.4 x 2.0 x 1.4 cm to 5.0 x 4.5 x 4.2 cm. In this group, there were no automatic shut-offs at any of the energy durations, and the lesions produced ranged from 1.3 x 1.3 x 1.1 cm (0.99 cm3) to 1.6 x 2.7 x 2.2 cm (5.03 cm3). The average ablation volumes produced were 1.76 cm3 at 30 seconds' RF application, 2.42 cm3 at 45 seconds, 3.96 cm3 at 60 seconds, and 5.03 cm3 at 90 seconds. Histologic examination revealed typical coagulation necrosis in the treatment zone without tissue desiccation. Introduction of the saline-electrode through a flexible cystoscope provides a minimally invasive procedure that quickly and controllably produces large lesions that may provide effective treatment for benign prostatic hyperplasia with less patient discomfort.

Pressure measurements during injection of corticosteroids.

Corticosteroid injection into the orbit, eyelid and larynx is a common treatment for inflammation and neoplasm. Complications include embolisation into the ocular circulation resulting in permanent loss of vision. The overall aim of the reported research is to develop an injection cannula and monitoring system which can prevent inadvertent embolisation into the ocular circulation during injection of corticosteroids. To that end, a special cannula was designed that allows simultaneous estimation of pressure at the tip of the cannula and flow rate during injection. The cannula was tested with backpressures corresponding to physiological ranges of 0 to 125 mmHg and injection flow rates of 3 to 11 cm3 min-1. The estimated pressure at the tip of the cannula during injection of corticosteroids was compared with direct pressure measurements. The results show that the mean estimated pressure is linearly related to the mean measured pressure with a slope of 0.99 and correlation coefficient of 0.99. Statistical analyses show that with standard error of estimate (SEE) of 2.14 mmHg, the estimated pressure is well within the 95% prediction interval limits of the measured values. The estimation of pressure from the cannula and monitoring system was accurate and warrants further testing in animal models.

Transurethral prostate ablation with saline electrode allows controlled production of larger lesions than conventional methods.

A novel technique for prostate ablation using radiofrequency (RF) energy coupled to tissue with interstitial perfusion of saline solutions from a screw-tip catheter has been developed. The electrolyte spreads the current density away from the metal electrode and increases the effective electrode surface area, allowing more RF power input. This prevents tissue desiccation and impedance rise, resulting in controlled production of large lesions. In this study, we attempted to produce similar results using a straight needle and the saline electrode with a transurethral approach and compared the results with those of the same technique without electrolyte perfusion (conventional RF method). For this study, we designed an insulated 22-gauge needle with thermocouples embedded along its length and a 1-cm exposed tip with a retractable intraluminal thermocouple. This needle was inserted into the urethra of 10 dogs through a small perineal incision. Under transrectal ultrasound guidance, the exposed tip of the needle was placed in the center of each lobe. The intraluminal thermocouple was moved from the exposed tip up to the prostate capsule to monitor temperature. The highest power that could be applied in conventional RF methods without immediate desiccation was determined from preliminary experiments as 10 W. Subsequently, 10 W of RF power (475 kHZ) was delivered in one lobe until either the capsule temperature reached 48 degrees C or high impedance (> 400 omega) occurred. In the other lobe, 50 W of RF energy (475 kHz) and electrolyte perfusion (14.6% NaCl, 1 mL/min) were delivered until the capsule temperature reached 48 degrees C or high impedance occurred. Prostate lobe sizes ranged from 3.93 cm3 to 44.47 cm3 (mean 15.07 cm3). At 10 W without saline perfusion, high impedance from tissue desiccation occurred at 45 +/- 27 seconds, with lesions ranging from 0.06 cm3 to 0.93 cm3 (mean 0.34 cm3). At 50 W with saline perfusion, there was no tissue desiccation or impedance rise. The RF application time averaged 181 +/- 115 seconds until the capsule reached 48 degrees C, resulting in lesions ranging from 2.53 cm3 to 22.88 cm3 (mean 8.54 cm3). This study demonstrates that transurethral ablation of the prostate with a saline electrode allows controlled production of larger lesions than conventional RF methods. This may permit a single RF application in each lobe to produce lesions effective for the treatment of benign prostatic hyperplasia even in large glands.

Ex vivo experiment on radiofrequency liver ablation with saline infusion through a screw-tip cannulated electrode.

PURPOSE: To investigate whether radiofrequency (RF) therapy with hypertonic saline infusion through a hollow screw-tip electrode can cause a lesion size suitable for liver tumor ablation. MATERIALS AND METHODS: RF tissue ablation of 180 sites was performed by using a hollow screw-tip electrode in 40 freshly excised swine livers. Under both power and temperature control modes, the ablation effects with and without various regimes of 5% hypertonic saline (1 ml/min) prior to and/or during the procedure were compared by measuring the size of lesions at dissection and confirmed by T1 and T2 weighted magnetic resonance (MR) imaging. RESULTS: The maximal lesion diameter of 5.5 cm was reached at 30 W with saline infusion 1 min prior to and during 12 min of ablation. The smaller sizes (P < 0.01) between 0.3 and 2.5 cm in diameter were met with noninfusion or preinfusion-only groups. The RF ablation lesions appeared as hyper- and hypointense areas on T1 and T2 MR images, respectively. CONCLUSIONS: RF ablation in combination with present hollow screw-tip electrode and saline infusion allows for necrotic development of suitable size for liver tumor ablation. Such ablated lesions can be visualized with MR imaging.

Childhood burns in camping and outdoor cooking accidents: a focus for prevention.

We have seen increasing numbers of children who present with serious burns related to camping and outdoor cooking, prompting this 5-year review. Of 34 children (21 boys and 13 girls), with an average age of 5.2 years (4 months to 17 years) and average burn size of 15% (1% to 98%) cared for (4 as outpatients and 30 as inpatients), there was one fatality (3%). Mechanisms of injury included falling into free pits, throwing flammables into grills or pits, placing hands on hot objects in or near a fire, walking or falling into hot embers from an extinguished fire, spills from insect repellant candies, tent fires, burning of paper eating utensils, and cooking scalds. We have initiated a directed prevention program with the regional state park systems.

The National Maternity Hospital casualty department--a review.

This is a review of obstetrical and gynaecological patients presenting to our maternity unit after clinic hours from 1991 to 1993. Patient data was collected prospectively. The number of patients seen after clinic hours increased by 35%, from 2241 in 1991, to 3014 in 1993. Analysis of data from 1991 revealed that the majority of patients were self referred, General Practitioner referrals accounting for only 9% of patients seen. Antenatal patients were the largest group at 77%, 10% were postnatal and 13% had gynaecological complaints. Unbooked patients presenting with first trimester bleeding accounted for one third of all antenatal patients. Thirty eight percent of patients seen were admitted. The number of out-of-clinic hours patients constituted a sizeable proportion of our hospital population. We conclude that this service is a necessary and important part of patient care at a large maternity unit.

Enhanced radiofrequency ablation of canine prostate utilizing a liquid conductor: the virtual electrode.

Conventional radiofrequency (RF) ablative techniques have shown promise for the treatment of symptomatic benign prostatic hyperplasia (BPH); however, present RF technology is limited by the small lesion size, necessitating several probe placements and heating cycles to achieve sizable lesions. This limitation is attributable primarily to a rapid increase in electrical impedance secondary to tissue desiccation and charring at the electrode tip. We devised a hollow screw-tip needle electrode that permits fixation to tissue, recording of temperature and impedance, infusion of fluid, and delivery of RF energy. Infusion of electrolyte solution (i.e., saline) into tissue prevents impedance rise by conducting RF energy away from the metal electrode and permits the creation of large lesions. By varying the conductivity of the perfusate (concentration and temperature), lesions of large diameter can be created in a controlled manner. To determine the long-term tissue effects, we applied this new modified RF technique to the prostates of five mongrel dogs in a chronic (0.5 to 8-week) study. The screw-tip electrode was serially embedded into each lobe of the perineally exposed glands with 1-minute infusion of 0.9% saline (2 mL/min) followed by application of RF energy (500 KHz, 50 W, 2-18 minutes) along with continuous saline infusion. Thermocouples were embedded 5 mm below and at the gland capsule, and RF application was discontinued when the temperature reached 50 degrees C at the periphery. Postoperatively, the animals were examined daily for clinical status and weekly for glandular changes using transrectal ultrasonography. At predetermined intervals, the animals were sacrificed and the prostates excised, measured, sectioned, and examined for histologic changes. Ablative tissue temperatures of 50 to 100 degrees C were produced while impedance remained stable. Four animals required a single catheterization for relief of urinary retention between days 2 and 3; otherwise, all animals demonstrated a quick and uneventful recovery with no edema detectable on day 7 ultrasound examination. The outside dimensions of the gland remained relatively constant throughout the study (+ or - 0.39 cm L + W + H). Histologic examination revealed coagulation necrosis (ablation) in both lobes of all prostates (69.94% + or - 16.62% of the gland) with tissueless cavities forming from the ablation area (28.71% + or - 8.24% of the gland) contained within the capsule surrounded by healthy tissue at the periphery. Intraprostatic lesions were obtained without any gross damage to surrounding tissue, including the bladder and rectal wall. Utilizing a liquid conductor in prostate tissue allows a single electrode-placement heating cycle for controlled ablation for the potential treatment of BPH. This new technique produces more extensive and uniform lesions than conventional RF procedures, and lesion size is limited only by the duration of RF energy application.

Identification and selective inhibition of four distinct soluble forms of cyclic nucleotide phosphodiesterase activity from kidney.

Homogenization of rat kidney under isotonic conditions and in the presence of protease inhibitors showed that some 92% of the cyclic AMP phosphodiesterase activity and some 83% of the cyclic GMP phosphodiesterase activity was released into the soluble fraction. Analysis of soluble phosphodiesterase activity by FPLC on a Mono-Q column resolved four distinct fractions expressing cyclic nucleotide phosphodiesterase activity. Lineweaver-Burk plots for the hydrolysis of both cyclic GMP and cyclic AMP yielded linear results. The first two peaks (KPDE-MQ-II, KPDE-MQ-III) showed higher activities towards cyclic GMP than cyclic AMP with the ratio of their Vmax values for the hydrolysis of cyclic AMP/cyclic GMP being 0.66 and 0.16, respectively. For the second two peaks (KPDE-MQ-IV, KPDE-MQ-V) the Vmax ratios for the hydrolysis of cyclic AMP/cyclic GMP were 6.4 and 16.7, respectively. All enzymes exhibited similar low Km values for both cyclic AMP and cyclic GMP but had very different Vmax values. KPDE-MQ-II was activated by Ca2+/calmodulin. The cyclic AMP phosphodiesterase activity of KPDE-MQ-III was augmented by the presence of low concentrations of cyclic GMP. Thermal denaturation studies showed that the phosphodiesterase activity of each fraction decayed as a single exponential indicating that each phosphodiesterase fraction contained but a single phosphodiesterase activity. The inhibitors IBMX, zaprinast, milrinone, amrinone, buquineran, carbazeran, ICI 118233, ICI 63197 exerted selective effects on the activities of these enzymes. We compared the action of these compounds on cyclic GMP phosphodiesterases from bovine retina. Over the concentration ranges used, the bovine retinal enzyme was only inhibited by IBMX, zaprinast and carbazeran. The cytosolic isoenzymes of cyclic AMP phosphodiesterases play a much more important role in metabolizing cyclic AMP in kidney compared with liver, where the activity of membrane-bound isoenzymes predominate.

A double-blind crossover comparison of Sinemet CR4 and standard Sinemet 25/100 in patients with Parkinson's disease and fluctuating motor performance.

Fourteen Parkinsonian patients with fluctuations in therapeutic response to levodopa completed a double-blind, crossover trial of controlled-release levodopa/carbidopa (Sinemet CR4) vs standard Sinemet 25/100 (STD). Significant increases in mean interdose interval and per cent of the waking day spent "on", as well as reductions in the number of daily medication doses and number of "off" episodes were noted. In the double-blind part of the study, relative to open treatment with STD, ten patients rated themselves as improved while taking CR4, whereas only three considered themselves improved with STD. Difficulties using CR4 included an increased "lag-time" to the onset of antiparkinson effect, a tendency to produce increasingly severe dyskinesia late in the day, and a somewhat lessened predictability of motor response. Nonetheless, since the overall level of motor function through the day was equal to or better than that attained with STD, but with fewer medication administrations, Sinemet CR4 should prove a useful antiparkinsonian agent.

Controlled-release levodopa/carbidopa. III: Sinemet CR5 treatment of response fluctuations in Parkinson's disease.

Five patients with advanced Parkinson's disease and fluctuations in therapeutic response to levodopa participated in, and four completed, an open label study of the efficacy of Sinemet CR5. Reductions in the number of daily doses and "off" periods as well as the increase in interdose interval and percent "on" time versus standard Sinemet were comparable to those achieved with Sinemet CR4 in these same patients. As compared with Sinemet CR4, there was a greater delay in the occurrence of peak plasma levodopa concentrations, and relative bioavailability was reduced. Sinemet CR5 appears to offer no advantages over Sinemet CR4 in the treatment of response fluctuations in Parkinson's disease.

Purification and properties of L-mandelate dehydrogenase and comparison with other membrane-bound dehydrogenases from Acinetobacter calcoaceticus.

L-Mandelate dehydrogenase was purified from Acinetobacter calcoaceticus by Triton X-100 extraction from a 'wall + membrane' fraction, ion-exchange chromatography on DEAE-Sephacel, (NH4)2SO4 fractionation and gel filtration followed by further ion-exchange chromatography. The purified enzyme was partially characterized with respect to its subunit Mr (44,000), pH optimum (7.5), pI value (4.2), substrate specificity and susceptibility to various potential inhibitors including thiol-blocking reagents. FMN was identified as the non-covalently bound cofactor. The properties of L-mandelate dehydrogenase are compared with those of D-mandelate dehydrogenase, D-lactate dehydrogenase and L-lactate dehydrogenase from A. calcoaceticus.

Membrane-bound lactate dehydrogenases and mandelate dehydrogenases of Acinetobacter calcoaceticus. Location and regulation of expression.

Acinetobacter calcoaceticus possesses an L(+)-lactate dehydrogenase and a D(-)-lactate dehydrogenase. Results of experiments in which enzyme activities were measured after growth of bacteria in different media indicated that the two enzymes were co-ordinately induced by either enantiomer of lactate but not by pyruvate, and repressed by succinate or L-glutamate. The two lactate dehydrogenases have very similar properties to L(+)-mandelate dehydrogenase and D(-)-mandelate dehydrogenase. All four enzymes are NAD(P)-independent and were found to be integral components of the cytoplasmic membrane. The enzymes could be solubilized in active form by detergents; Triton X-100 or Lubrol PX were particularly effective D(-)-Lactate dehydrogenase and D(-)-mandelate dehydrogenase could be selectively solubilized by the ionic detergents cholate, deoxycholate and sodium dodecyl sulphate.

Unwinding of the DNA helix in simian virus 40 chromosome templates by RNA polymerase.

We measured the distortion of the DNA helix by RNA polymerase transcribing simian virus 40 (SV40) chromosome templates and compared it with the distortion caused by the enzymes as it transcribes naked SV40 DNA, using RNA polymerase from Escherichia coli. Purified DNA topoisomerase I was added to the transcription reactions and the number of supercoil turns in DNA, after deproteinising and removal of RNA, was determined by gel electrophoresis and band-counting. The number of polymerase molecules bound per naked DNA molecule was determined by electron microscopy. Each bound RNA polymerase distorted the template in such a way as to lead to on apparent average of 0.6-0.7 negative superhelical turn in the extracted DNA. Thus only few base-pairs are melted per RNA polymerase molecule. When SV40 chromosomes were transcribed the extracted DNA had a higher number of supercoil turns than DNA extracted from the initial chromosomes. We conclude that the polymerase deforms the DNA in chromatin in the same way as it deforms pure DNA. From control experiments with inhibitors of initiation we estimated that on average 9-10 RNA polymerase molecules were bound per SV40 chromosome. This suggests that transcription can proceed while the majority or all the nucleosomal structures are intact on an SV40 DNA molecule. We discuss the implications of these findings for the mechanism of transcription of chromatin.