Female gender and diabetes mellitus increase the risk of recurrence after laparoscopic incisional hernia repair.

BACKGROUND: Laparoscopic hernia repair is used widely for the repair of incisional hernias. Few case studies have focussed on purely 'incisional' hernias. This multicentre series represents a collaborative effort and employed statistical analyses to provide insight into the factors predisposing to recurrence of incisional hernia after laparoscopic repair. A specific hypothesis (ie, laterality of hernias as well as proximity to the xyphoid process and pubic symphysis predisposes to recurrence) was also tested. METHODS: This was a retrospective study of all laparoscopic incisional hernias undertaken in six centres from 1 January 2004 to 31 December 2010. It comprised a comprehensive review of case notes and a follow-up using a structured telephone questionnaire. Patient demographics, previous medical/surgical history, surgical procedure, postoperative recovery, and perceived effect on quality of life were recorded. Repairs undertaken for primary ventral hernias were excluded. A logistic regression analysis was then fitted with recurrence as the primary outcome. RESULTS: A total of 186 cases (91 females) were identified. Median follow-up was 42 months. Telephone interviews were answered by 115/186 (62%) of subjects. Logistic regression analyses suggested that only female sex (odds ratio (OR) 3.53; 95% confidence interval (CI) 1.39-8.97) and diabetes mellitus (3.54; 1-12.56) significantly increased the risk of recurrence. Position of the defect had no statistical effect. CONCLUSIONS: These data suggest an increased risk of recurrence after laparoscopic incisional hernia repair in females and subjects with diabetes mellitus. These data will help inform surgeons and patients when considering laparoscopic management of incisional hernias. We recommend a centrally hosted, prospectively maintained national/international database to carry out additional research.

Root biomass production in populations of six rooted macrophytes in response to Cu exposure: intra-specific variability versus constitutive-like tolerance.

Intra-specific variability of root biomass production (RP) of six rooted macrophytes, i.e. Juncus effusus, Phragmites australis, Schoenoplectus lacustris, Typha latifolia, Phalaris arundinacea, and Iris pseudacorus grown from clones, in response to Cu exposure was investigated. Root biomass production varied widely for all these macrophytes in control conditions (0.08 µM) according to the sampling site. Root biomass production of T. latifolia and I. pseudacorus in the 2.5-25 µM Cu range depended on the sampling location but not on the Cu dose in the growth medium. For P. australis, J. effusus, S. lacustris, and P. arundinacea, an intra-specific variability of RP depending on both the sampling location and the Cu-dose was evidenced. This intra-specific variability of RP depending on the sampling location and of Cu-tolerance for these last four species suggests that Cu constitutive tolerance for all rooted macrophytes is not a species-wide trait but it exhibits variability for some species.

Salt or sugar for your injured brain? A meta-analysis of randomised controlled trials of mannitol versus hypertonic sodium solutions to manage raised intracranial pressure in traumatic brain injury.

BACKGROUND: Rising intracranial pressure (ICP) is a poor prognostic indicator in traumatic brain injury (TBI). Both mannitol and hypertonic sodium solutions are used to treat raised ICP in patients with TBI. OBJECTIVE: This meta-analysis compares the use of mannitol versus hypertonic sodium solutions for ICP control in patients with TBI. DATA SOURCES AND STUDY ELIGIBILITY: Randomised clinical trials in adults with TBI and evidence of raised ICP, which compare the effect on ICP of hypertonic sodium solutions and mannitol. METHODS: The primary outcome measure is the pooled mean reduction in ICP. Studies were combined using a Forest plot. RESULTS: Six studies were included, comprising 171 patients (599 episodes of raised ICP). The weighted mean difference in ICP reduction, using hypertonic sodium solutions compared with mannitol, was 1.39 mm Hg (95% CI -0.74 to 3.53). LIMITATIONS: Methodological differences between studies limit the conclusions of this meta-analysis. CONCLUSIONS: The evidence shows that both agents effectively lower ICP. There is a trend favouring the use of hypertonic sodium solutions in patients with TBI.

Peak plasma anti-Xa levels after first and third doses of enoxaparin in women receiving weight-based thromboprophylaxis following caesarean section: a prospective cohort study.

BACKGROUND: Women undergoing caesarean section are at higher risk for thromboembolic complications following delivery than other parturients. The aim of this study was to determine whether higher doses of enoxaparin based on body weight are safe and more likely to achieve plasma anti-Xa levels within the accepted thromboprophylactic range. METHODS: We undertook a prospective cohort study of 80 women undergoing caesarean section in a tertiary obstetric hospital with >6000 deliveries per year. Enoxaparin was administered after caesarean section using the Royal College of Obstetricians and Gynaecologists weight-adjusted dosing guidelines. Plasma anti-Xa levels were measured at baseline and 3-4 h after enoxaparin administration on days one and three postoperatively. The main outcomes of interest were plasma anti-Xa levels and the proportion of patients with plasma anti-Xa levels in the range of 0.2-0.4 IU/mL. RESULTS: The proportion of women with anti-Xa levels between 0.2 and 0.4 IU/mL was 72% (95% CI 60-81%). Unadjusted mean anti-Xa levels were 0.26 ± 0.09 IU/mL and 0.28 ± 0.08 IU/mL on day one and day three respectively. No woman had levels >0.48 IU/mL. CONCLUSION: The majority of women receiving weight-based enoxaparin thromboprophylaxis following caesarean section achieved plasma anti-Xa levels within the putative thromboprophylactic range. No woman achieved levels associated with an increased risk of bleeding (>0.8 IU/mL). These findings provide a safety basis for a large prospective study using this regimen.

Compartmentalization of wards to cohort symptomatic patients at the beginning and end of norovirus outbreaks.

BACKGROUND: Outbreaks of norovirus can have a significant operational and financial impact on healthcare establishments. AIM: To assess whether containment of symptomatic patients in single rooms and bays at the beginning and end of norovirus outbreaks reduced the length of bed closure. METHODS: In 2007, we introduced a new strategy to limit the operational impact of hospital outbreaks of norovirus. Early in an outbreak, symptomatic patients were cohorted in single rooms or bays in an attempt to contain the outbreak without closing the entire ward. Once a ward had been closed, and as beds became available through discharges, patients were decanted into single rooms or empty bays with doors to facilitate earlier cleaning and opening of affected areas on the same ward. The impact of these changes was assessed by comparing outbreak data for two periods before and after implementation of the new strategy. FINDINGS: Prior to June 2007, 90% of outbreaks were managed by closure of an entire ward, compared with only 54% from June 2007 onwards. The duration of closure was significantly shorter for bays compared with entire wards, both before (3.5 vs 6, P = 0.0327) and after (3 vs 5, P < 0.0001) June 2007. When considering all outbreaks, there was a significant reduction in duration of closure after the change in strategy (6 vs 5, P = 0.007). CONCLUSION: Using ward compartmentalization to cohort affected patients at the beginning and end of norovirus outbreaks improved the efficiency of outbreak management and reduced operational disruption.

Anti-planetward auroral electron beams at Saturn.

Strong discrete aurorae on Earth are excited by electrons, which are accelerated along magnetic field lines towards the planet. Surprisingly, electrons accelerated in the opposite direction have been recently observed. The mechanisms and significance of this anti-earthward acceleration are highly uncertain because only earthward acceleration was traditionally considered, and observations remain limited. It is also unclear whether upward acceleration of the electrons is a necessary part of the auroral process or simply a special feature of Earth's complex space environment. Here we report anti-planetward acceleration of electron beams in Saturn's magnetosphere along field lines that statistically map into regions of aurora. The energy spectrum of these beams is qualitatively similar to the ones observed at Earth, and the energy fluxes in the observed beams are comparable with the energies required to excite Saturn's aurora. These beams, along with the observations at Earth and the barely understood electron beams in Jupiter's magnetosphere, demonstrate that anti-planetward acceleration is a universal feature of aurorae. The energy contained in the beams shows that upward acceleration is an essential part of the overall auroral process.

Postoperative epidural analgesia following elective major abdominal surgery in high risk patients: a retrospective cohort study.

AIM: To describe the effect of post-operative epidural analgesia on morbidity and mortality rates in a group of high-risk patients undergoing elective major abdominal surgery. METHODS: Retrospective chart review of patients in American Society of Anaesthetists Physical Status (ASA) category III or IV, who underwent elective major I or II general surgical procedures between 01/01/1996 and 01/09/1998. Patients were identified from a prospective audit database. Patients who had epidural analgesia or conventional parenteral opioids were compared for outcome measures. RESULTS: There were 167 patients identified (72 epidural, 95 non-epidural group). There was no significant difference in demographic data, inpatient stay, intensive care unit stay, or mortality rates (11% epidural v 17% non-epidural, p>0.05). There was no significant difference in morbidity rates, however there was a non-significant trend towards a lower morbidity in the epidural group. CONCLUSIONS: This study does not show any benefit from post-operative epidural analgesia on morbidity and mortality rates in high risk patients undergoing major abdominal surgery. It does illustrate that ASA 3 and 4 patients undergoing major abdominal surgery have a high morbidity and mortality.

Identification of STKA-dependent genes in Dictyostelium discoideum.

During culmination of Dictyostelium aggregates, prespore and prestalk cells undergo terminal differentiation to form spores and a cellular stalk. Disruption of the cell-fate gene stkA leads to a phenotype in which all the cells destined to become spores end up as stalk cells. 'Stalky' mutants express normal levels of prespore cell transcripts but fail to produce the culmination-stage spore transcript spiA. The stkA gene encodes a putative GATA-type transcription factor (STKA). In order to identify possible downstream targets of STKA we used the technique of mRNA differential display and isolated four cDNA fragments that hybridise to mRNAs present during the later stages of development. All four gene tags were cloned and sequenced. mRNAs represented by these four sequence tags do not accumulate during culmination of 'stalky' cells and therefore must be specific to the spore pathway. By screening a cDNA library, longer cDNAs for all four were cloned and sequenced. Three of these contained complete protein-coding regions while only a partial cDNA was recovered for the fourth. One of the corresponding proteins has significant homology to a surface zinc metalloproteinase (GP63) of the protozoan parasite Leishmania, while another is closely related to a human pre-RNA binding protein (hnRNP R).

Pyridoxal kinase knockout of Dictyostelium complemented by the human homologue.

The gene (pykA) encoding pyridoxal kinase which converts pyridoxal (vitamin B(6)) to pyridoxal phosphate was isolated from Dictyostelium discoideum using insertional mutagenesis. Cells of a pykA gene knockout grew poorly in axenic medium with low yield but growth was restored by the addition of pyridoxal phosphate. Sequencing indicated a gene, with one intron, encoding a predicted protein of 301 amino acids that was 42% identical in amino acid sequence to human pyridoxal kinase. After expression of the wild-type gene in Escherichia coli, the purified PykA protein product was shown to have pyridoxal kinase enzymatic activity with a K(m) of 8.7 microM for pyridoxal. Transformation of the Dictyostelium knockout mutant with the human pyridoxal kinase gene gave almost the same level of complementation as that seen using transformation with the wild-type Dictyostelium gene. Phylogenetic analysis indicated that the Dictyostelium amino acid sequence was closer to human pyridoxal kinase than to pyridoxal kinases of lower eukaryotes.

Affect and cognition in dreams: a critique of the cognitive role in adaptive dream functioning and support for associative models.

Dream affect and cognition are examined in a 4-month longitudinal study of depressed, recently divorced subjects. Several measures of cognition in dream reports were used to determine whether remitting subjects were more likely to utilize certain cognitive strategies than nonremitters. No differences were found in the cognition between those who were remitting and nonremitting subjects. Levels of cognition in dreaming were directly related to the emotional intensity of the dreams across all subjects. In subjects with higher depression scores (Beck Depression Inventory > 20), depression levels were inversely related to both dream affect and cognition. It is argued that cognition plays a secondary role in dream production. A modification of David Foulkes's model of dreaming is proposed, in which emotional intensity drives associative processes, which in turn require more elaborate cognitive devices to relate diverse activated mnemonic units.

A negative regulatory element in a prespore-specific promoter of dictyostelium discoideum(1).

We previously isolated several 'promoter-trap' transformants in which insertion of a promoterless beta-galactosidase gene into the genome caused expression of beta-galactosidase in specific cell types. The upstream flanking region was rescued from one transformant specifically expressing beta-galactosidase in prespore cells. We sequenced the promoter of the gene that is fused in-frame with lacZ and characterised a negative element that inhibits expression in pstO cells (a subtype of prestalk cells). Gel-retardation assays show that a developmentally regulated factor(s) recognises and binds to this element.

A myb-related protein required for culmination in Dictyostelium.

The avian retroviral v-myb gene and its cellular homologues throughout the animal and plant kingdoms contain a conserved DNA binding domain. We have isolated an insertional mutant of Dictyostelium unable to switch from slug migration to fruiting body formation i.e. unable to culminate. The gene that is disrupted, mybC, codes for a protein with a myb-like domain that is recognized by an antibody against the v-myb repeat domain. During development of myb+ cells, mybC is expressed only in prestalk cells. When developed together with wild-type cells mybC- cells are able to form both spores and stalk cells very efficiently. Their developmental defect is also bypassed by overexpressing cAMP-dependent protein kinase. However even when their defect is bypassed, mybC null slugs and culminates produce little if any of the intercellular signalling peptides SDF-1 and SDF-2 that are believed to be released by prestalk cells at culmination. We propose that the mybC gene product is required for an intercellular signaling process controlling maturation of stalk cells and spores and that SDF-1 and/or SDF-2 may be implicated in this process.

Isolation of spermidine synthase gene (spsA) of Dictyostelium discoideum.

The gene encoding spermidine synthase (spsA) was isolated from Dictyostelium discoideum using the technique of insertional mutagenesis. Northern blot analysis showed that the spsA mRNA is expressed maximally during the vegetative stage and decreases gradually during the 24 h of development. Sequencing of the genomic DNA and a full-length cDNA clone indicated the presence of one intron in a gene coding for a predicted protein (SpsA) with 284 amino acids. The sequence is highly conserved, with amino acid identities compared to spermidine synthases of humans, 59.5%, to mouse, 61.3%, and to yeast, 58.1%. A null mutant of the spsA gene is unable to grow in the absence of exogenous spermidine. Development of spsA null cells grown in the absence of spermidine produced fruiting bodies that have abnormally short stalks.

Hospital library service and the changes in national standards.

Two important sets of standards affecting hospital libraries were significantly revised in 1994, those of the Medical Library Association (MLA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). As part of its continuing efforts to monitor library services within its region, the University of California, Los Angeles Biomedical Library, Regional Medical Library for the Pacific Southwest Region of the National Network of Libraries of Medicine (NN/LM) conducted a survey in late 1994, in part to determine the effects of these revised standards on regional hospital libraries. Data from the survey were also used to provide a view of hospital libraries in the Pacific Southwest region, and to make comparisons with similar data collected in 1989. Results showed that while libraries remained stable in overall number, size, and staffing, services, especially those associated with end-user searching and interlibrary loan, increased enormously. With respect to the MLA standards, results show a high compliance level. Interesting differences were seen between the perceptions of library staff concerning their rate of compliance with the JCAHO standards and their actual compliance as measured by the MLA criteria. While some libraries appear to measure up better than their own perceptions would indicate, others may be fully aware of their actual compliance level.

An IgG monoclonal antibody against Dictyostelium discoideum glycoproteins specifically recognizes Fucalpha1,6GlcNAcbeta in the core of N-linked glycans. Localized expression of core-fucosylated glycoconjugates in human tissues.

Core fucosylation of N-linked oligosaccharides (GlcNAcbeta1, 4(Fucalpha1,6)GlcNAcbeta1-Asn) is a common modification in animal glycans, but little is known about the distribution of core-fucosylated glycoproteins in mammalian tissues. Two monoclonal antibodies, CAB2 and CAB4, previously raised against carbohydrate epitopes of Dictyostelium discoideum glycoproteins (Crandall, I. E. and Newell, P. C. (1989) Development 107, 87-94), specifically recognize fucose residues in alpha1,6-linkage to the asparagine-bound GlcNAc of N-linked oligosaccharides. These IgG3 antibodies do not cross-react with glycoproteins containing alpha-fucoses in other linkages commonly seen in N- or O-linked sugar chains. CAB4 recognizes core alpha1,6 fucose regardless of terminal sugars, branching pattern, sialic acid linkage, or polylactosamine substitution. This contrasts to lentil and pea lectins that recognize a similar epitope in only a subset of these structures. Additional GlcNAc residues found in the core of N-glycans from dominant Chinese hamster ovary cell mutants LEC14 and LEC18 progressively decrease binding. These antibodies show that many proteins in human tissues are core-fucosylated, but their expression is localized to skin keratinocytes, vascular and visceral smooth muscle cells, epithelia, and some extracellular matrix-like material surrounding subpopulations of lymphocytes. The availability of these antibodies now allows for an extended investigation of core fucose epitope expression in development and malignancy and in genetically manipulated mice.

Identification of the cell fate gene stalky in Dictyostelium.

Using insertional mutagenesis, we have isolated a "stalky" mutant in which cells destined to become spores end up as stalk cells. Similar mutants were previously observed after chemical mutagenesis, but the affected gene could not be isolated. Our mutant, like the previous ones, is in stkA. Its defect is cell-autonomous and not overcome by overexpressing cAMP-dependent protein kinase. stkA is strongly expressed in the prespore region of aggregates but not in the anterior prestalk zone. The mutant expresses normal levels of prespore-cell transcripts but fails to produce the spore transcript spiA. stkA encodes a predicted 99 kDa protein (STKA) with two putative C4 zinc fingers, one of which is a GATA-type finger, indicating that it may be a transcription factor. This conclusion is supported by localization of STKA in the nucleus.