Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion.

BACKGROUND: Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention is a benchmark for the quality of care provided by pediatric urologists included in US News and World Report (USNWR) methodology. OBJECTIVE: We sought to optimize management of acute testicular torsion at a single institution by decreasing time from presentation to definitive management through the creation and implementation of a clinical care pathway (accelerated care of torsion or ACT) for acute testicular torsion in a 2-year period. STUDY DESIGN: Multidisciplinary process mapping involving the emergency department (ED), radiology, anesthesiology, peri-operative services, and operating room (OR) teams resulted in development of the ACT pathway with the goal of achieving surgical intervention within 4 h of arrival at our institution. The accelerated care of torsion pathway was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. For process measures, we recorded triage to OR times and mode of presentation. For outcome measures, we examined orchiectomy rates. We retrospectively reviewed 97 cases of acute torsion from 2004 to 2016 as a control. RESULTS: Time from ED triage to OR start decreased from a median 196 min (interquartile range [IQR] 137-249 min) to 127 min (IQR 100-148 min; P < 0.0001) for all cases of acute torsion. In the control group, 72% of cases met the USNWR criteria for acute treatment of torsion. After ACT implementation, 100% of cases reached the OR within the 240 min time frame. Orchiectomy rates were performed in 24% of control cases vs 30% after ACT implementation (P = NS). Survival curve analysis demonstrated no significant difference in probability of testis salvage before or after implementation of the ACT pathway. DISCUSSION: In agreement with similar studies, despite a significant reduction in triage to OR times, the orchiectomy rate approached 30%. This outcome did not significantly improve after implementation of the ACT pathway. Overall ischemia time was a more important determinant of testis salvage. Study limitations include limited patient follow-up to assess testis atrophy. CONCLUSIONS: The multidisciplinary creation and implementation of a clinical pathway for the care of acute testis torsion has significantly decreased the time from ED to OR in our institution. However, overall orchiectomy rate was not significantly affected.

Diuresis renography in the evaluation and management of pediatric hydronephrosis: What have we learned?

Diuresis renography (DR) is widely used in the evaluation of hydronephrosis and hydroureter in infants and children. The goal of this provocative nuclear imaging examination should be to detect the hydronephrotic kidneys at risk for loss of function and development of pain, hematuria, and urinary tract infection. The reliability of DR is dependent on the acquisition and processing of the data as well as interpretation and utilization of the results. In this review, the key concepts of standardized DR and pitfalls to avoid are highlighted.

The outcome and complications of vascularised fibular grafts.

AIMS: Free vascularised fibular grafting has been used for the treatment of large bony defects for more than 40 years. However, there is little information about the risk factors for failure and whether newer locking techniques of fixation improve the rates of union. The purpose of this study was to compare the rates of union of free fibular grafts fixed with locking and traditional techniques, and to quantify the risk factors for nonunion and failure. PATIENTS AND METHODS: A retrospective review involved 134 consecutive procedures over a period of 20 years. Of these, 25 were excluded leaving 109 patients in the study. There were 66 men and 43 women, with a mean age of 33 years (5 to 78). Most (62) were performed for oncological indications, and the most common site (52) was the lower limb. Rate of union was estimated using the Kaplan-Meier method and risk factors for nonunion were assessed using Cox regression. All patients were followed up for at least one year. RESULTS: The rate of union was 82% at two years and 97% at five years. Union was achieved after the initial procedure in 76 patients (70%) at a mean of ten months (3 to 19), and overall union was achieved in 99 patients (91%). No surgical factor, including the use of locked fixation or supplementary corticocancellous bone grafts increased the rate of union. A history of smoking was significantly associated with a risk of nonunion. DISCUSSION: Free vascularised fibular grafting is a successful form of treatment for large bony defects. These results suggest that the use of modern techniques of fixation does not affect the risk of nonunion when compared with traditional forms of fixation, and smoking increases the risk of nonunion following this procedure. Cite this article: Bone Joint J 2017;99-B:134-8.

Differences in Virulence Between Bovine-Derived Clinical Isolates of Pasteurella multocida Serotype A from the UK and the USA in a Model of Bovine Pneumonic Pasteurellosis.

The time of onset and subsequent degree and progression of clinical signs, bacterial colonization and tissue pathology during experimental disease induced by intratracheal inoculation of either a UK or USA isolate of Pasteurella multocida serotype A recovered from clinical cases of bovine pneumonia were determined. Calves aged 8 weeks were challenged with 300 ml phosphate buffered saline (PBS) alone (group 1, n = 3, negative control) or containing 7.1 × 10(8) colony forming units (cfu) of UK isolate (group 2, n = 8) or 5.8 × 10(8) cfu of USA isolate (group 3, n = 8). Bronchoalveolar lavage (BAL) at 0, 1 and 4 days post challenge (dpc) and at the time of necropsy examination (7-8 dpc) showed no significant differences between groups 2 and 3 in bacterial numbers recovered. No P. multocida were recovered from group 1 animals. No clinical disease was present in group 1 calves and in group 3 was limited to scour in 1 calf at 1 dpc. All calves in group 2 had reduced food intake at 4-5 dpc, five had periods of dullness, three a mild nasal discharge at 1 dpc, four had mild to substantial respiratory stridor and one was killed at 6 dpc for humane reasons. Rectal temperatures remained about 39°C in group 1 calves, but increased in P. multocida-challenged calves to 40-41°C within 8-12 h of challenge. Significantly (P = 0.01) greater percentages of lung surface area were consolidated in group 2 (mean ± SD, 21 ± 10.1) compared with group 3 (7 ± 8.6) calves. Significantly more extensive and severe histological lesions were present in the lung lobes (P = 0.006) and lymph nodes (P = 0.02) of group 2 compared with group 3 calves. Pleurisy was present in group 2 calves only and no pathology was present in group 1. Pulsed-field gel electrophoresis (PFGE) produced 11 (group 2, UK isolate) or 10 (group 3, USA isolate) bands with differences in banding patterns. Results overall showed that two isolates, distinct geographically and genetically (by PFGE), caused pneumonic pasteurellosis in a single host with significantly different severity of pathology. This information is relevant to the development of novel vaccine control and interpretation of diagnostic results.

Molluscan cells in culture: primary cell cultures and cell lines.

In vitro cell culture systems from molluscs have significantly contributed to our basic understanding of complex physiological processes occurring within or between tissue-specific cells, yielding information unattainable using intact animal models. In vitro cultures of neuronal cells from gastropods show how simplified cell models can inform our understanding of complex networks in intact organisms. Primary cell cultures from marine and freshwater bivalve and gastropod species are used as biomonitors for environmental contaminants, as models for gene transfer technologies, and for studies of innate immunity and neoplastic disease. Despite efforts to isolate proliferative cell lines from molluscs, the snail Biomphalaria glabrata Say, 1818 embryonic (Bge) cell line is the only existing cell line originating from any molluscan species. Taking an organ systems approach, this review summarizes efforts to establish molluscan cell cultures and describes the varied applications of primary cell cultures in research. Because of the unique status of the Bge cell line, an account is presented of the establishment of this cell line, and of how these cells have contributed to our understanding of snail host-parasite interactions. Finally, we detail the difficulties commonly encountered in efforts to establish cell lines from molluscs and discuss how these difficulties might be overcome.

Pathophysiology, prevention, and treatment of ebullism.

INTRODUCTION: Ebullism is the spontaneous evolution of liquid water in tissues to water vapor at body temperature when the ambient pressure is 47 mmHg or less. While injuries secondary to ebullism are generally considered fatal, some reports have described recovery after exposure to near vacuum for several minutes. The objectives of this article are to review the current literature on ebullism and to present prevention and treatment recommendations that can be used to enhance the safety of high altitude activities and space operations. METHODS: A systematic review was conducted on currently available information and published literature of human and animal studies involving rapid decompression to vacuum and ebullism, with subsequent development of an applicable treatment protocol. RESULTS: Available research on ebullism in human and animal subjects is extremely limited. Literature available identified key pathophysiologic processes and mitigation strategies that were used for treatment protocol design and outlining appropriate interventions using current best medical practices and technologies. DISCUSSION: Available literature suggests that the pathophysiology of ebullism leads to predictable and often treatable injuries, and that many exposures may be survivable. With the growing number of high altitude and space-related activities, more individuals will be at risk for ebullism. An integrated medical protocol can provide guidance for the prevention and treatment of ebullism and help to mitigate this risk in the future.

Seven strains of mice as potential models of bovine pasteurellosis following intranasal challenge with a bovine pneumonic strain of Pasteurella multocida A:3; comparisons of disease and pathological outcomes.

The gram-negative bacterium Pasteurella multocida causes pneumonic and systemic pasteurellosis in bovids for which vaccines are either unavailable or inadequate. The work assessed whether an intranasal P. multocida challenge in mice might provide a model of infection for future vaccine development work. Clinical, pathological and biochemical responses were compared in seven strains of mice challenged with a virulent bovine pneumonic isolate of P. multocida A:3. Six mouse strains (Porton, CD-1, BALB/c, VM, C57BL/10 and C57BL/6) developed clinical signs of pneumonic disease and variable pneumonic lesions 41-70 h post-infection. In contrast, mouse strain RIII became septicaemic within 36 h post-infection. Concentrations of plasma acute phase proteins and serum lipopolysaccharide increased in all mice after infection, and the main or interaction effect of mouse strain and infection status was statistically significant (P<0.05). Responses in C57BL/10 mice showed close similarity to bovine pneumonic and in RIII mice to bovine systemic pasteurellosis.

Investigations into an outbreak of corvid respiratory disease associated with Pasteurella multocida.

The possible cause of disease and mortality in corvids on an outdoor pig unit in the north of England between August 2007 and March 2008 was investigated. Nine carrion crows (Corvus corone corone) and nine rooks (Corvus frugilegus), comprising five live-caught birds with clinical signs of respiratory disease, one live-caught bird without respiratory disease, and 12 birds submitted dead were examined. Clinical signs, gross and histopathological examination, microbiology and toxicology indicated that Pasteurella multocida infection was the cause of disease. Molecular and serotyping analyses showed that P. multocida isolates (obtained from live-caught birds with clinical respiratory disease) were all capsular type F with a mix of somatic serotypes 3, 4 and 7. Immunohistochemistry increased the diagnostic sensitivity of the analysis and detected P. multocida within the pulmonary lesions of all affected live-caught birds and 10 of 12 birds found dead. These findings suggest that wild corvids in the UK can suffer from lung pathology associated with P. multocida and, as potential vectors of P. multocida, may pose a risk to domestic poultry.

Characterization and time course of pulmonary lesions in calves after intratracheal infection with Pasteurella multocida A:3.

Pasteurella multocida A:3 is a common cause of suppurative bronchopneumonia in calves and results in significant production losses and mortality. Here we describe the lesions in three calves at each of four time points (1 day and 4, 7 and 10 days) after experimental intratracheal infection with approximately 1x10(9) colony-forming units of P. multocida A:3 Moredun Research Institute (MRI isolate 671/90). Equivalent age- and time-matched sham-dosed negative control animals were also studied. Infected calves developed significantly elevated mean rectal temperatures (P<0.001) and respiratory rates (P<0.001) compared with negative control animals. Extensive consolidation of multiple lung lobes was present on each of the day/s post-infection (dpi). Histologically, large numbers of alveoli contained either or both polymorphonuclear neutrophils (PMNs) and oedema fluid (1 dpi). At 4 dpi a severe fibrinosuppurative bronchopneumonia had developed. At this time, PMNs and macrophages formed focal lesions containing central necrotic and mineralized debris, while the interlobular septa were severely distended by oedema. Early abscess formation was present in the lung parenchyma at 7 dpi and many of the interlobular septa were thrombosed. At 10 dpi abscesses within the lung parenchyma were mature and comprised of central necrosis with surrounding layers of PMN, macrophages and fibrous tissue. This study describes, for the first time, the commencement, nature and progression of lesions in bovine pneumonic pasteurellosis caused by P. multocida A:3 and provides the foundations for further investigation of the pathogenesis of this disease in cattle.

New diagnostic and information technology for mobile medical care.

Medicare reimbursement for home visits average around $100 without ancillaries, so making 10 home visits to prevent even a single $1,000 ambulance ride is cost-neutral for Medicare. Home medical care is only an added cost if it fails to offset acute care use. The government's demographic and financial pressure suggests a need to press ahead with the enhanced mobile care model, so the explosion in point-of-care devices should continue. The main challenge is to decide which ones provide dispositive value to patients.

Gene expression in the liver of rainbow trout, Oncorhynchus mykiss, during the stress response.

To better appreciate the mechanisms underlying the physiology of the stress response, an oligonucleotide microarray and real-time RT-PCR (QRT-PCR) were used to study gene expression in the livers of rainbow trout (Oncorhynchus mykiss). For increased confidence in the discovery of candidate genes responding to stress, we conducted two separate experiments using fish from different year classes. In both experiments, fish exposed to a 3 h stressor were compared to control (unstressed) fish. In the second experiment some additional fish were exposed to only 0.5 h of stress and others were sampled 21 h after experiencing a 3 h stressor. This 21 h post-stress treatment was a means to study gene expression during recovery from stress. The genes we report as differentially expressed are those that responded similarly in both experiments, suggesting that they are robust indicators of stress. Those genes are a major histocompatibility complex class 1 molecule (MHC1), JunB, glucose 6-phosphatase (G6Pase), and nuclear protein 1 (Nupr1). Interestingly, Nupr1 gene expression was still elevated 21 h after stress, which indicates that recovery was incomplete at that time.

Contribution of respiratory burst activity to innate immune function and the effects of disease status and agent on chemiluminescence responses by ruminant phagocytes in vitro.

The mechanisms of interaction between phagocytes and different bacteria that help resolve lung infections or contribute to lung pathology are poorly defined. Alveolar phagocytes (resident macrophages and recruited neutrophils) make a major contribution to innate immunity by mounting a respiratory burst that helps kill internalised bacteria. However, this ability may be altered during or after exposure to infection. This review considers the application and limitations of a variety of analytical methods for oxygen-dependent mechanisms of respiratory burst in phagocytes initiated by soluble and particulate activators. Particular reference is given to the study in vitro of phagocytes from healthy and diseased ruminants during either natural infection with Mycobacterium avium paratuberculosis or experimental infection with Pasteurella multocida or Mannheimia haemolytica.

Cloning of Schistosoma mansoni sporocysts in vitro and detection of genetic heterogeneity among individuals within clones.

The establishment of in vitro cultivation techniques to maintain larval and adult stages of the trematode Schistosoma mansoni has facilitated research on diverse aspects of the biology of this parasite. Because of the difficulty in obtaining defined intramolluscan stages of this parasite, one aim of this study was to develop an in vitro technique for the generation of defined clonal daughter sporocyst (DSp) generations that originate from a single mother sporocyst. Sporocysts died when cultured singly; however, when single sporocysts were cultured in inserts within wells with about 1,000 others, the single individuals produced daughters asexually. In recent years, evidence has been accumulating for variability among, and within, schistosome populations. Such variability has been seen in both larval and adult stages. Even within clonal cercariae, genomic and biochemical heterogeneity has been observed, indicating the existence of a yet unknown mechanism that generates variability during larval development. Therefore, another aim of this study was to examine clonal DSps generated in vitro for diversity regarding the presence or absence of a specific repetitive DNA element (W1). Such sporocysts were found by molecular analysis to be heterogeneous with respect to the occurrence of W1. This phenomenon had previously been observed in clonal schistosome populations and described as genomic instability. In this study, we provide the first molecular evidence that variability can be generated within sporocyst generations, supporting the hypothesis of mitotic recombination events during the asexual life stage of schistosomes.

Induction of 5alpha-reductase type II mRNA transcription in primary cultured prostate epithelial cells by a soluble factor produced by primary cultured prostate fibroblast cells.

The role of DHT in the development of BPH has resulted in the formulation of several drugs, which have been designed to inhibit the formation of DHT by the 5alpha-reductase enzymes (5alpha-reductase type I (5alpha-RI) & 5alpha-reductase type II (5alpha-RII)). Although the function of these enzymes is well understood, the biochemical stimulus for initiation of 5alpha-RI and II gene expression has not been described. Study of a co-culture model indicated the presence of a diffusible factor secreted by prostatic fibroblast cells, which is responsible for the transcription of 5alpha-II mRNA in primary prostatic epithelial cells. In this study, we describe the partial characterisation of a fibroblast-secreted, soluble factor which we believe induces the transcription of 5alpha-RII mRNA in long-term primary cultures of prostate epithelial cells which can no longer transcribe 5alpha-RII mRNA.

MUC1 expression, splice variant and short form transcription (MUC1/Z, MUC1/Y) in prostate cell lines and tissue.

OBJECTIVE: To detect the expression and transcription pattern of MUC1 in benign and malignant disease, and in two widely studied cell lines, and to investigate the glycosylation of MUC-1 in bone metastasis of prostate cancer, as mucins have been implicated in the progression and behaviour of several cancers. MATERIALS AND METHODS: RNA extracted from cell lines (DU145 and PC3), five samples of BPH and five samples of prostate cancer was reverse transcribed before amplification of MUC1-specific sequences by polymerase chain reaction. Paraffin-embedded sections were stained for glycosylated MUC1 and MUC1 core epitopes by HMFG1 and B27.29 antibodies, respectively. Steroid-treated cell lines were analysed by fluorescence-activated cell sorting, using the same antibodies. RESULTS: MUC1, in an under-glycosylated form, was widely expressed in the prostate and in metastatic lesions. MUC1/Z and MUC1/Y RNA were differentially expressed in BPH and prostate cancer, with no detectable expression of splice variant mRNA. This is in contrast to prostate cancer cell line cells (PC3 and DU145), which express splice variant mRNA. CONCLUSIONS: BPH, prostate cancer and metastatic prostate cancer all express high levels of under-glycosylated MUC1. This may explain the inability of previous studies to detect MUC1 in prostate tissue, as the antibody used was specific for a carbohydrate epitope which is not expressed on the under-glycosylated MUC1.

The acute phase response of rainbow trout (Oncorhynchus mykiss) plasma proteins to viral, bacterial and fungal inflammatory agents.

The innate arm of the immune system responds to inflammatory stimuli by the activation of phagocytes, and by altered levels of several plasma proteins. These changes in plasma proteins comprise a major component of the acute phase response, which is thought to be an adaptive response that contributes to regaining homeostasis after tissue injury or infection. In this study, rainbow trout (Oncorhynchus mykiss) were injected with a variety of potential inflammatory agents, and changes in the concentrations of plasma proteins were sought in polyacrylamide gels in which plasma proteins had been electrophoresed. Bacteria, viruses and yeast all induced changes in plasma protein profiles. Increases were first evident 2 days after injections, and most were evident within 1 week. The greatest number of changes occurred after injection with a Vibrio bacterin emulsified in Freund's incomplete adjuvant. While some proteins increased and others decreased following several treatments, other proteins changed only in response to injections of viruses or viral proteins, and others changed in response to bacterial components. Some proteins that increased after yeast injection decreased after injection of viral components. The partial amino acid sequence of one increased protein identified it as haptoglobin.

Expression of oestrogen receptor beta (ERbeta1) protein in human breast cancer biopsies.

Oestrogen action is mediated via specific receptors that act as ligand-activated transcription factors. A monoclonal antibody specific to the C-terminus of human oestrogen receptor beta has been characterized and the prevalence of expression of oestrogen receptor beta protein investigated in a well defined set of breast cancers. Reverse transcription-polymerase chain reaction analysis of RNA from tissue biopsies detected oestrogen receptor beta in all samples examined. The anti-oestrogen receptor beta antibody cross reacted specifically with both long (approximately 59 Kd) and short (approximately 53 Kd) forms of recombinant oestrogen receptor beta. Western blot analysis of breast tumours contained both forms of oestrogen receptor beta protein although in some samples lower molecular weight species (32--45 Kd) were identified. Fifty-one breast cancer biopsies were examined using immunohistochemistry; 41 (80%) were immunopositive for oestrogen receptor alpha, 48 (94%) were immunopositive for oestrogen receptor beta and 38 (74.5%) co-expressed both receptors. Expression of oestrogen receptor beta was exclusively nuclear and occurred in multiple cell types. There was no quantitative relationship between staining for the two ERs although in tumours in which both receptors were present immunoexpression of oestrogen receptor alpha was invariably more intense. The significance of oestrogen receptor beta protein expression in breast cancers to therapy remains to be determined but the availability of a well characterized antibody capable of detecting oestrogen receptor beta in archive material will facilitate the process.

Axenic culture of Schistosoma mansoni sporocysts in low O2 environments.

Recent successes in culturing intramolluscan larval stages of Schistosoma mansoni have relied on synxenic culture with a cell line (Bge) developed from embryos of a molluscan host Biomphalaria glabrata. To further facilitate progress toward control of schistosomiasis, a system for axenic in vitro culture of the parasite has now been developed. When culture media were preconditioned by Bge cells, sporocysts lived longer in vitro and produced more offspring. Because Bge-derived components could be protecting sporocysts from oxidative stress, axenic sporocysts were cultured at lowered O2 levels. In an hypoxic environment, S. mansoni sporocysts grew well and produced daughter sporocysts continuously under axenic conditions and in a medium completely lacking host molecules. Sporocyst production occurs independently of host influence.