Group B streptococcal cervical osteomyelitis in a neonate.

Neonatal cervical osteomyelitis is extremely rare, with only a few reported cases. In most instances, Staphylococcus aureus is the infecting organism. The authors report a case of group B streptococcal osteomyelitis affecting the cervical spine. This case highlights the diagnostic and therapeutic difficulties that these cases present, and emphasises the role of a multidisciplinary team approach to management.

Dialysis membrane-dependent removal of middle molecules during hemodiafiltration: the beta2-microglobulin/albumin relationship.

AIM: Current hemodialysis therapy modalities such as online hemodiafiltration (HDF) attempt to enhance solute removal over a wide molecular weight range through a combination of diffusion and convection. While the effects of variations of treatment modalities and conditions have been studied reasonably well, few studies have examined the efficacy of HDF to remove middle molecules in relation to the dialyzer and membrane characteristics. In this investigation, diverse high-flux dialyzers, covering a wide range of membrane permeabilities, were compared under identical in vivo conditions to assess their ability to eliminate larger uremic retention solutes (using beta2-microglobulin as a surrogate of middle molecules) without simultaneously causing excessive leakage of useful proteins such as albumin. PATIENTS AND METHODS: In a prospective, crossover study, 3 ESRD patients were treated with 8 different brands of high-flux dialyzers at 4 different ultrafiltration (UF)/substitution flow rates (QS: 0, 30, 60, 90 ml/min) in post-dilution HDF mode. Thus, each patient underwent 32 treatment sessions, with a total of 96 treatment sessions conducted during the entire clinical study. Albumin and beta2-microglobulin levels were measured in both, dialysate and blood. Both, albumin and beta2-microglobulin elimination was dependent upon the permeability of the dialysis membrane as well as on the ultrafiltration/substitution flow rates applied. RESULTS: At the maximum UF rate of 90 ml/min, the total albumin loss (measured in the dialysate) ranged from 300 mg/4 h (for the FLX-15 GWS dialyzers) to 7,000 mg/4 h (for the BS-1.3U dialyzers). Up to 50% reduction of albumin occurred within the first 30 minutes of the dialysis treatment, and the leakage of albumin increased exponentially with increasing UF rates as well as increasing transmembrane pressure (TMP). The various dialyzers could be classified according to their UFR-dependent beta2-m reduction rates (RR), into low (< 50%; FLX-15 GWS, CT 150G), medium (50-70%; Polyflux 14 S, BLS 814SD, H4) and high (> 70%; BS-1.3U, APS 650, FX 60) removers of middle molecules. One dialyzer type (CT 150G) showed extremely low beta2-m RR and relatively high albumin losses. Most membranes, however, showed either low albumin leakage coupled with low beta2-m removal, or high beta2-m RR but at the expense of considerable albumin leakage. Only 2 membrane types approached the desired balance between high to medium beta2-m RR while simultaneously restricting the albumin leakage especially at higher filtration/substitution rates. CONCLUSION: Our investigations demonstrate that not all dialysis membranes classified as "high-flux" are comparable in their ability to specifically and efficiently remove middle molecules, or curtail the unwanted excessive leakage of essential proteins from the patient's blood. Thus, the selection of appropriate high-flux dialyzers for specific patient requirements should be based more upon clinical evaluations and analyses rather than on product specifications alone.

Psycho-socio-economic outcomes in acoustic neuroma patients and their carers related to tumour size.

The objective was to explore psycho-socio-economic outcomes of a 2-year cohort of patients having surgery for an acoustic neuroma, and carers and their relationship to tumour size after surgery. The Wessex Patient Carer Questionnaire was designed in conjunction with Patients and Carers, to determine psycho-socio-economic outcomes. The results were juxtaposed against clinical profiles. The House-Brackman (HB) scale was used to assess facial function at 6 and 12 months after operation. The cohort contained 102 patients. There were 87% effective responders. Half were aged below 54 years and 30% had school-aged children. The majority (93%) of patients were operated via the translabyrinthine approach. Patients with large tumours, i.e. greater than 3 cm (28%), had most post-treatment physical problems, including hearing and balance difficulties, and 42% reported difficulty eating in public. Thirty-four per cent felt 'stressed' and 18%'depressed'. After 6 months, facial function was recorded as HB scale 5/6 in 21% of patients but by 1 year only 8% of patients were HB 5/6. Patients and carers were generally very satisfied with their in-patient neurosurgical care, but significantly dissatisfied with post-discharge care - particularly the shortcoming of the community services. The majority of families felt 'unsupported' and only 20% of patients had confidence in their General Practitioner's knowledge. Families faced severe socio-economic disruption and patients"time-off-work' was estimated to cost pound 954,000. Carers carried considerable post-discharge psychological burdens and costs to the public purse were calculated to be pound 52,000.

Two-year prospective study of psychosocial outcomes and a cost-analysis of 'treatment-as-usual' versus an 'enhanced' (specialist liaison nurse) service for aneurysmal sub arachnoid haemorrhage (ASAH) patients and families.

An 18-month retrospective study of 'treatment-as-usual' of aneurysmal subarachnoid haemorrhage (ASAH, n = 142) used as control to compare prospective study (n = 184) of an 'enhanced' ('Specialist Liaison Nurse'-SLN) service to reduce psychosocial trauma. Consultant notes, Glasgow Coma Scores and 'High Risk' bleeds scores provided clinical data. A standardized patient/carer designed questionnaire provided psychosocial data, plus a cost-analysis. The cohorts were good clinical and social matches. Sixty-five per cent of patients had 'high risk' bleeds, and 81% were Grade 1 and 2 on the GCS, 54% aged less than 55 years, 83% belonged to social classes 1-3 and 32% had school-aged children. Satisfaction with SLN inpatient and discharge care increased significantly, with reduced psychosocial trauma. The SLN produced net 'savings' of pounds sterling 155,000 p.a., from reduced time-off work, medical time and re-admissions. Prospectively, pounds sterling 1.6 + million annual 'savings' were identified on 80% of employed patients returning to work. Long-term dysfunctional stress is not inevitable for most ASAH patients as a SLN is clinically and fiscally cost-effective.

Sphenoid wing meningioma en plaque: a clinical review.

OBJECTIVE: To review the role of craniofacial resection and reconstruction in the treatment of patients with sphenoid wing meningioma en plaque. DESIGN: 15 patients were reviewed. The presenting features, operative details and complications were documented. The adequacy of resection was reviewed and postoperative scans were analyzed to assess orbital reconstruction. Patients were assessed regarding aesthetics and craniofacial function. The Glasgow outcome scale and the SF36 questionnaire were used to assess outcome. RESULTS: The majority (92%) presented with proptosis and had disease extending from the sphenoid wing into the orbital roof (71%) and the middle fossa (71%). The transzygomatic approach was the most commonly used approach (85%). 14 patients were examined on an outpatient basis, one patient has died. In the majority of patients visual acuity was unchanged (85%) and in most cases (85%) there was significant improvement in globe position. Ptosis (57%) and upper eyelid swelling (50%) were a persistent problem. Craniofacial function and cosmesis were well maintained. Two patients have had clinical recurrences (14%). 14 have had a good outcome adjudged by the Glasgow outcome scale and most patients have satisfactory outcomes adjudged by the SF36 questionnaire. CONCLUSIONS: Meningioma en plaque represents a difficult surgical challenge requiring a multidisciplinary approach. By using well established craniofacial techniques good disease control can be achieved with minimal morbidity and good functional and cosmetic results.

Intra-aortic balloon counterpulsation: augmentation of cerebral blood flow after aneurysmal subarachnoid haemorrhage.

OBJECTIVE: To measure cerebral blood flow before and after intra-aortic balloon counterpulsation (IABC) in patients at high risk of developing delayed cerebral ischaemia after aneurysm surgery following subarachnoid haemorrhage. METHODS: Six prospectively selected patients at high risk of developing delayed ischaemia had elective IABC after clipping of their cerebral aneurysm(s). The IAB inflates in early diastole and deflates at the end of diastole to increase cardiac perfusion and decrease afterload. This results in enhanced cardiac efficiency. It also augments cerebral blood flow (CBF). RESULTS: We demonstrated a significant increase in the mean hemispheric CBF from the preoperative (preIABC) value of 35.6 mls/100 g/min to 50.9 +/- 12.3 mls/100 g/min (p = 0.0042) as a result of balloon augmentation. Each patient developed a neurological deficit as a result of delayed cerebral ischaemia. These were reversed in 5 patients with increased CBF. There were minimal balloon related complications. CONCLUSION: IABC consistently enhanced CBF in these patients and resulted in stable cardiovascular parameters. This represents a possible new technique in the management of cerebral ischaemia following subarachnoid haemorrhage and needs further assessment to ascertainlits role.

Extended transbasal approach with preservation of olfaction: ananatomical study.

Many craniofacial approaches to the sphenoethmoidal region, anterior fossa, and central skull base compartment have been described, a number of which involve the mobilization of the frontonasoorbital complex en bloc. Spetzler's modification incorporates osteotomies around the cribriform plate, to preserve olfaction. In this morphological study of three cadavers, photographs were used to show the technique and define its anatomical boundaries and limitations. The study illustrates access to a number of anatomical regions, particularly the exposure of the medial orbit, the cavernous sinus, the clivus, and the vertebrobasilar complex.

Psychosocial outcomes for patients and carers after aneurysmal subarachnoid haemorrhage.

As part of a 'clinical governance' initiative, a patient/carer led study was designed to determine the psychosocial outcome of a consecutive cohort of 137 aneurysmal sub-arachnoid haemorrhage (ASAH) patients of whom 45% had experienced a severe haemorrhage. Most patients were middle class (51%), female (63%), aged under 54 years (53%) and 30% had school-age children. Information booklets did not meet the need for case-specific answers and communication problems were identified despite the high rating of in-patient treatment. Substantial problems occurred after discharge because of a hiatus in care and support by community-based services. Carers carried major psychosocial burdens, fifty-one per cent reporting that their work was negatively affected, and after a year, employment cost to carers was pounds sterling 182,000 and pounds sterling 590,000 for patients. 11% of patients lost their jobs as a direct consequence of the ASAH. A cost-feasible solution to improve the communication-support problems was identified by these 'consumers'.

Mechanisms to improve teamworking in neurosurgery.

Team-working has been seen as an important essential in the delivery of modern medical care and quality. It should increase the range of skills and knowledge in dealing with clinical problems and needs to make better use of scarce professional resources. In addition many see the team as reducing the risk of the harmful consequences of idiosyncratic practice. Team-working requires a named consultant to be responsible for individual patients with corporate responsibility for the practice. Doctors and managers will need to work together. The structure of teams will by necessity change but the requirements are constant. These are to provide a basis for continuing professional development, the monitoring of standards of performance and capacity, and above all, to improve patient care and outcome. An essential prerequisite is the provision of resources to provide a supportive environment if clinical excellence is to be the norm.

Principles and problems of assessing the results of medical treatment.

The integration of clinical expertise with the best available evidence from systematic research is the foundation of evidence-based medicine (EBM). The results from a well-designed randomised controlled trial (RCT) is regarded as the best evidence on which to base treatment. In neurosurgical practice fewer treatments are based on the results of RCTs than in medical practice. The reasons are historical, ethical, practical and can be compounded by the surgical learning curve. In neurosurgical practice treatment protocols and surgical indications vary widely. In addition there is a lack of patient orientated, disease specific and generic outcome measures. However, it is a neurosurgical responsibility to provide hierarchical evidence upon which treatment can be based. Comparative audit may offer a solution provided there is high quality data collection, relevant measures of outcome, a defined case-mix and a representative population. Comparative audit can produce bias but neurosurgeons will need to meet the challenge of EBM. Their patients will expect it.

Crystal structure of pseudomonas aeruginosa lipase in the open conformation. The prototype for family I.1 of bacterial lipases.

The x-ray structure of the lipase from Pseudomonas aeruginosa PAO1 has been determined at 2.54 A resolution. It is the first structure of a member of homology family I.1 of bacterial lipases. The structure shows a variant of the alpha/beta hydrolase fold, with Ser(82), Asp(229), and His(251) as the catalytic triad residues. Compared with the "canonical" alpha/beta hydrolase fold, the first two beta-strands and one alpha-helix (alphaE) are not present. The absence of helix alphaE allows the formation of a stabilizing intramolecular disulfide bridge. The loop containing His(251) is stabilized by an octahedrally coordinated calcium ion. On top of the active site a lid subdomain is in an open conformation, making the catalytic cleft accessible from the solvent region. A triacylglycerol analogue is covalently bound to Ser(82) in the active site, demonstrating the position of the oxyanion hole and of the three pockets that accommodate the sn-1, sn-2, and sn-3 fatty acid chains. The inhibited enzyme can be thought to mimic the structure of the tetrahedral intermediate that occurs during the acylation step of the reaction. Analysis of the binding mode of the inhibitor suggests that the size of the acyl pocket and the size and interactions of the sn-2 binding pocket are the predominant determinants of the regio- and enantio-preference of the enzyme.

Outcome from complex neurosurgery: an evidence based approach.

BACKGROUND: The aim of this study was to determine outcome, including quality of life, after surgery for petroclival meningioma using a standard skull base approach and to carry out an evidence based appraisal of the relevant literature. METHOD: Pre- and post-operative data including adverse events were prospectively recorded in 19 patients (15 females, age range 29-63) undergoing a transpetrous approach for a petroclival meningioma. Patients were assessed using the GOS and SF-36 post operatively. FINDINGS: 24 operations were done. 6 patients developed a new permanent neurological deficit and 10 experienced a temporary deficit or exacerbation of existing deficits. At 1 year 15 patients had made a good/moderate recovery, 3 were severely disabled and 1 died--in keeping with other studies. By contrast the SF-36 showed that in all 8 categories of the SF-36 between 39-72% of surviving patients were functioning below the accepted norms. INTERPRETATION: After transpetrous excision of a petroclival meningioma the quality of life for the patient is worse than that indicated in surgeons' reported results. This paper represents an attempt to address the issue of evidence-based medicine and finds that such an approach is not apparent in the medical literature on this pathology. While we argue that methods for measuring outcome should be refined and carers input recognised it does raise certain philosophical considerations. It is the counsel of perfection and if achieved may lead to surgeons operating on fewer patients, more petroclival cases being viewed as inoperable because of the higher morbidity, despite there being an inescapable pathway to surgical intervention.

Crystallization and preliminary X-ray diffraction analysis of the NAD-dependent non--phosphorylating GAPDH of the hyperthermophilic archaeon Thermoproteus tenax.

Recombinant non-phosphorylating NAD(+)-dependent glyceraldehyde-3-phosphate dehydrogenase (GAPN) of the hyperthermophilic crenarchaeote Thermoproteus tenax has been overexpressed, purified and crystallized using the hanging-drop vapour-diffusion technique. Crystals of different habits were obtained from several precipitant solutions (salts and polyethylene glycols). Preliminary X-ray analysis was performed with crystals grown in ammonium formate, which belonged to the primitive hexagonal space group P622, and had unit-cell parameters a = b = 184.8, c = 133.0 A, gamma = 120 degrees. Assuming a molecular weight of 55 kDa, a Matthews parameter of 3.3 A(3) Da(-1) is calculated assuming two molecules per asymmetric unit. The diffraction limit of these crystals is 2.5 A resolution.

Outcome after complex neurosurgery: the caregiver's burden is forgotten.

OBJECT: The goals of this study were twofold: 1) to determine outcome, including quality of life, in patients who have undergone surgery for petroclival meningioma in which a standard skull base approach was used; and 2) to assess the impact of the patients' surgical treatment on their caregivers. METHODS: Seventeen patients (13 women and four men ranging in age from 29 to 63 years) who underwent a transpetrosal approach for a petroclival meningioma during a 5-year period were prospectively included in this study. Pre- and postoperative data including adverse events were noted. The patients were assessed at 3, 6, and 12 months postoperatively, and annually thereafter, and they completed a postoperative SF-36 questionnaire. In addition, each patient's caregiver was interviewed to determine the effect of the patient's illness on the caregiver's life and responsibilities. Twenty-two operations were performed. A new permanent neurological deficit developed in five patients and in eight a temporary deficit or exacerbation of existing deficits occurred. Two patients underwent surgery to create a facial-hypoglossal nerve communication; five required a temporary percutaneous gastrostomy and/or tracheostomy; three required a shunt; and one underwent successful squint surgery. At 1 year postoperatively 13 patients had made a good or moderate recovery, three were severely disabled, and one had died--outcomes in keeping with other studies. By contrast, responses to the SF-36 questionnaire showed that, in all eight of its categories, between 43% and 75% of surviving patients were functioning below accepted norms. Fifty-six percent of caregivers experienced a major change in lifestyle and 38% experienced a major change with respect to their work. CONCLUSIONS: After transpetrosal excision of a petroclival meningioma, the quality of life for the patient is worse than that indicated in surgeons' reported results. The impact on the patient's caregiver is profound-a burden perhaps not fully appreciated by the surgeon.

Efficient expression, purification and crystallisation of two hyperthermostable enzymes of histidine biosynthesis.

Enzymes from hyperthermophiles can be efficiently purified after expression in mesophilic hosts and are well-suited for crystallisation attempts. Two enzymes of histidine biosynthesis from Thermotoga maritima, N'-((5'-phosphoribosyl)-formimino)-5-aminoimidazol-4-carb oxamid ribonucleotide isomerase and the cyclase moiety of imidazoleglycerol phosphate synthase, were overexpressed in Escherichia coli, both in their native and seleno-methionine-labelled forms, purified by heat precipitation of host proteins and crystallised. N'-((5'-phosphoribosyl)-formimino)-5-aminoimidazol-4-carb oxamid ribonucleotide isomerase crystallised in four different forms, all suitable for X-ray structure solution, and the cyclase moiety of imidazoleglycerol phosphate synthase yielded one crystal form that diffracted to atomic resolution. The obtained crystals will enable the determination of the first three-dimensional structures of enzymes from the histidine biosynthetic pathway.

The extended transbasal approach: a quantitative anatomical and histological study.

Since its introduction in 1972 the transbasal approach to the anterior fossa and sphenoethmoidal region has undergone a number of modifications. The extended transbasal approach with preservation of olfaction not only improves exposure of the anterior fossa, but also provides access to the clivus as far inferiorly as the foramen magnum. An anatomical study has been undertaken to photographically demonstrate and quantify the varying degrees of exposure that this technique provides. The pituitary stalk was used as an intracranial target. The amount of exposure was compared using a standard subfrontal approach, a transbasal approach and an extended transbasal with preservation of olfaction. In addition, a histological study was carried out to investigate the level to which identifiable olfactory nerves extended into the nasal mucosa. The anatomical study demonstrates the area of the "external window of exposure" can be doubled using a transbasal approach and more than quadrupled using the extended transbasal approach, when gaining access to the pituitary stalk. In addition, the study highlights the exposure of other anatomical areas, such as the medial orbit, the cavernous sinus, the clivus and the vertebrobasilar complex. The histological study establishes that the olfactory nerves extend only 10 mms below the cribriform plate.

The extended transbasal approach: clinical applications and complications.

OBJECTIVES: To describe in detail key technical aspects of the extended transbasal approach which involves en-bloc mobilisation of the supraorbital rim, the orbital roof and the nasoethmoidal complex. In some patients osteotomies were performed around the cribriform plate with a view to maintaining olfaction. To review 18 patients with deep seated lesions located in the central skull base region (including 6 recurrences) to highlight patient selection, presentation, surgical morbidity and outcome. METHODS: Prospective data recording and clinical chart review. RESULTS: Outcome was assessed at a minimum of 1 year after operation using the Glasgow Outcome Score. Thirteen patients had made a good recovery, 1 was moderately disabled, 2 were severely disabled (both had been severely disabled before operation), and 2 died. By contrast, quality of life assessment indicated that only 7 of the surviving 14 adults had returned to normal levels of activity and perceived health; although 6 of the other 7 patients had resumed their former occupations, their follow up assessments showed a reduced quality of life. Of the 13 patients who had an olfaction preservation procedure, 6 showed appreciation of smell on formal testing. CONCLUSIONS: In patients with progressive and extensive deep seated lesions this technique provides wide exposure in a shallow surgical field. Complication rates although acceptable were significantly higher in patients with intradural lesions. In some selected patients it was possible to preserve olfaction. Specific surgical outcome assessments pointed to satisfactory results, but failed to reflect the degree of patient disability. There is a need for outcome measures that take into account the patient's expectations and which address his quality of life in order to validate the benefits of these procedures.

Case of the month: June 1998--2 year old boy with lumbosacral mass.

We report the case of a boy aged 2 years with spina bifida and a lipomyelomeningocele which contained ectopic immature renal tissue. He presented with a swelling over the lumbosacral region, incontinence, and bilateral leg weakness. Histopathologic examination revealed adipose tissue in which a focus of fibrous tissue contained neuroglial elements, striated muscle fibres and clusters of glomeruloid structures surrounded by immature tubules. The differential diagnosis of teratoma and lipomyelomeningocele with nephrogenic rests is discussed with reference to possible pathogenesis.

Structural basis of the chiral selectivity of Pseudomonas cepacia lipase.

To investigate the enantioselectivity of Pseudomonas cepacia lipase, inhibition studies were performed with Sc- and Rc-(Rp,Sp)-1,2-dialkylcarbamoylglycero-3-O-p-nitrophenyl alkylphosphonates of different alkyl chain lengths. P. cepacia lipase was most rapidly inactivated by Rc-(Rp,Sp)-1,2-dioctylcarbamoylglycero-3-O-p-nitrophenyl octylphosphonate (Rc-trioctyl) with an inactivation half-time of 75 min, while that for the Sc-(Rp,Sp)-1,2-dioctylcarbamoylglycero-3-O-p-nitrophenyl octyl-phosphonate (Sc-trioctyl) compound was 530 min. X-ray structures were obtained of P. cepacia lipase after reaction with Rc-trioctyl to 0.29-nm resolution at pH 4 and covalently modified with Rc-(Rp,Sp)-1,2-dibutylcarbamoylglycero-3-O-p-nitrophenyl butyl-phosphonate (Rc-tributyl) to 0.175-nm resolution at pH 8.5. The three-dimensional structures reveal that both triacylglycerol analogues had reacted with the active-site Ser87, forming a covalent complex. The bound phosphorus atom shows the same chirality (Sp) in both complexes despite the use of a racemic (Rp,Sp) mixture at the phosphorus atom of the triacylglycerol analogues. In the structure of Rc-tributyl-complexed P. cepacia lipase, the diacylglycerol moiety has been lost due to an aging reaction, and only the butyl phosphonate remains visible in the electron density. In the Rc-trioctyl complex the complete inhibitor is clearly defined; it adopts a bent tuning fork conformation. Unambiguously, four binding pockets for the triacylglycerol could be detected: an oxyanion hole and three pockets which accommodate the sn-1, sn-2, and sn-3 fatty acid chains. Van der Waals' interactions are the main forces that keep the radyl groups of the triacylglycerol analogue in position and, in addition, a hydrogen bond to the carbonyl oxygen of the sn-2 chain contributes to fixing the position of the inhibitor.