An improved retractor for the anterior approach in the surgical management of vertebral fractures.

Interest appears to be increasing in the anterior approach for the surgical management of thoracic and lumbar vertebral fractures. However, adequate exposure requires a self-retaining retractor system. Current stainless steel systems, by interfering with fluoroscopic visualization of bony fractures and landmarks, require frequent repositioning. We found that a newly available aluminum alloy retractor system provides excellent operative exposure without significant fluoroscopic obstruction. This system eliminates the frustration of frequent retractor repositioning and saves us an average of 20 to 30 minutes of operating room time per vertebral repair.

Interleukin-10 reduces morbidity and mortality in murine multiple organ dysfunction syndrome (MODS).

HYPOTHESIS: IL-10 will reduce morbidity and mortality in murine MODS. Introduction. Intraperitoneal (ip) zymosan causes a triphasic inflammatory process leading to MODS. Phase I is an acute systemic inflammatory response to sterile peritonitis. Phase II is the recovery phase. Phase III is characterized by recurrent illness, progressive organ dysfunction, and elevated proinflammatory cytokines. METHODS: Male ICR mice were randomized (on Experiment Day 0, time = 0 h) into four initial groups (A-D): Control Group A received no zymosan and no IL-10. Group B received zymosan (1 mg/g mouse BW, t = 0) and no IL-10. Group C received no zymosan and IL-10 at t = 2 h. Group D received zymosan and IL-10 at t = 2 h. On Experiment Day 4, mice in Groups B-D were randomized into six further treatment groups (B1 and B2, C1 and C2, D1 and D2). Group B1 received no treatment. Group B2 received IL-10 when clinical signs of recurrent illness developed (Phase III, 12-18 days after zymosan treatment). Mice were sacrificed when they were preterminal (clinical signs of shaking, shivering, or paralysis) or on Experiment Day 28 (survivors). Plasma total bilirubin and creatinine levels were measures of organ function. Terminal pulmonary compliance was measured in situ through a physiologic range of tidal volumes. RESULTS: Mice entering Phase III consistently progressed to MODS characterized by elevated bilirubin and hemorrhagic lungs which, if left untreated, was lethal. Mice treated with IL-10 (Group B2) when they entered Phase III had lower mortality (28.6% vs 100%, P < 0.02), longer survival (25 vs 18 days, P < 0.05), and improved lung pulmonary compliance (slope beta1 = 0.082 ml/mm Hg vs 0.059 ml/mm Hg, P < 0.001) compared to untreated (Group B1) mice in Phase III. CONCLUSIONS: IL-10 improves survival even when given after clinical signs of illness are present.

The enteric drained pancreas transplant: another potential source of gastrointestinal bleeding.

With most combined kidney and pancreas transplants the transplant pancreatic exocrine secretions are managed with urinary bladder drainage. Because of the associated metabolic and infectious complications, many pancreatic transplants require later conversion to enteric drainage, and the trend in this country is now toward primary enteric drainage. Unlike with urinary bladder drainage when direct cystoscopy can be performed, a disadvantage with enteric drainage is that problems such as bleeding from a transplanted pancreas and attached duodenal segment are not easily evaluated. A case of a cytomegalovirus-related bleeding ulcer in an enteric drained pancreas is presented, along with a review of the possible diagnostic evaluation.

The Little Rock weave.

A debate has raged in the surgical literature about the use of a running suture verses interrupted sutures for abdominal wound closures. For most abdominal wounds either method can probably be used safely. A modified interrupted technique is described which may be useful for some difficult wounds. One of the main advantages of this technique is that the wound tension is equally distributed along the entire wound and not only on the last placed suture. The sutures are easily tied without having "to fight the wound".

The anterior extrapleural approach to the thoracolumbar junction revisited.

General surgeons often provide the exposure for the anterior repair of vertebral body lesions. The standard anterior approach to the thoracolumbar junction (T11-L1) is a transpleural 9th or 10th rib thoracoabdominal incision. From October 1995 through March 1997, 22 patients underwent anterior repair of thoracolumbar junction vertebral lesions through an alternative 11th rib resection while maintaining an extrapleural approach. Exposure was excellent, as judged by the neurosurgical team completing the repairs. Chest tubes were not used routinely, and all patients healed without complications. A major limitation of the 11th rib extrapleural approach to the thoracolumbar junction has been poor exposure. This problem is eliminated with the use of an abdominal self-retaining retractor system. With many potential advantages to this 11th rib exposure (less pain, fewer pulmonary problems, and better wound healing), we consider the 11th rib incision to be the approach of choice to the thoracolumbar junction and recommend renewed interest in this incision.

A practical approach to laparoscopic surgery for malfunctioning peritoneal dialysis catheters.

Peritoneal dialysis is widely accepted for the chronic management of end-stage renal disease but is associated with as high as a 70% complication rate including a significant problem with peritoneal dialysis catheter flow obstruction. The application of laparoscopic surgical techniques has revolutionized the surgical approach to peritoneal dialysis catheter-related dysfunction. However, the specific laparoscopic surgical technique varied among the reported literature. This lack of a standard laparoscopic surgical approach to obstructed peritoneal dialysis catheters prompted us to review and compare our specific technique and experience in 17 patients with 10 recent reported series. We specifically examined for insufflation techniques, access port placements and closures, timing postoperatively for reinstituting peritoneal dialysis, wound complications, and overall long-term success rates for peritoneal dialysis catheter salvage.

Rapid mass spectrometric peptide sequencing and mass matching for characterization of human melanoma proteins isolated by two-dimensional PAGE.

We report a general mass spectrometric approach for the rapid identification and characterization of proteins isolated by preparative two-dimensional polyacrylamide gel electrophoresis. This method possesses the inherent power to detect and structurally characterize covalent modifications. Absolute sensitivities of matrix-assisted laser desorption ionization and high-energy collision-induced dissociation tandem mass spectrometry are exploited to determine the mass and sequence of subpicomole sample quantities of tryptic peptides. These data permit mass matching and sequence homology searching of computerized peptide mass and protein sequence data bases for known proteins and design of oligonucleotide probes for cloning unknown proteins. We have identified 11 proteins in lysates of human A375 melanoma cells, including: alpha-enolase, cytokeratin, stathmin, protein disulfide isomerase, tropomyosin, Cu/Zn superoxide dismutase, nucleoside diphosphate kinase A, galaptin, and triosephosphate isomerase. We have characterized several posttranslational modifications and chemical modifications that may result from electrophoresis or subsequent sample processing steps. Detection of comigrating and covalently modified proteins illustrates the necessity of peptide sequencing and the advantages of tandem mass spectrometry to reliably and unambiguously establish the identity of each protein. This technology paves the way for studies of cell-type dependent gene expression and studies of large suites of cellular proteins with unprecedented speed and rigor to provide information complementary to the ongoing Human Genome Project.

Structure and heterogeneity of the oligosaccharides from the lipopolysaccharides of a pyocin-resistant Neisseria gonorrhoeae.

The compositions and partial structures of the oligosaccharides from the lipopolysaccharides (LPS) of a pyocin-resistant Neisseria gonorrhoeae (strain JW31R) have been determined by liquid secondary ion mass spectrometry (LSIMS), tandem mass spectrometry, and methylation analysis. Four major structures were identified with Mr 2123, 2000, 1961, and 1838, as well as seven species of lower abundance of Mr 1758-1272. The largest of the major oligosaccharides (Mr, 2122) consists of 3-deoxymanno-2-ketooctulosonic acid (KDO)-Hep2GalNAcGlcNAcGal4Glc2 (Hep, heptose) and phosphoethanolamine (PEA). The smaller oligosaccharides are truncated versions of this larger oligosaccharide. The oligosaccharides consist of a common triantennary structure containing KDO at the reducing terminus attached to a heptose disaccharide. A hexose (Hex)2-3 branch is attached to the heptose linked directly to KDO and a GalNAc-Hex3, GlcNAc, and PEA are separately attached to the second heptose. These oligosaccharides are the first structures to be determined for a gonococcal LPS and should further our understanding of the structural and antigenic diversity of these glycolipids.

Structural characterization of intact, branched oligosaccharides by high performance liquid chromatography and liquid secondary ion mass spectrometry.

We report results of a mass-spectrometric-based strategy for determining the detailed structural features of N-linked oligosaccharides from glycoproteins. The method was used to characterize a series of intact, high mannose oligosaccharides isolated from human immunoglobulin M (IgM). The IgM was purified from a patient with Waldenstrom's macroglobulinemia. The strategy included releasing the oligosaccharides by digestion of the purified glycoprotein with endoglycosidase H, separating the released oligosaccharides by high resolution gel filtration, and derivatizing the resulting reducing termini with the uv-absorbing moiety, ethyl p-aminobenzoate. This particular derivative facilitates HPLC detection and provides centers for protonation and deprotonation enhancing liquid secondary ion mass spectra. Positive and negative ion spectra contained molecular species of similar abundance. However, fragment ion peaks yielding sequence information were significantly more prominent in the negative ion mass spectra. Furthermore, it was obvious that the fragmentation patterns differed substantially for linear and branched oligomers. For linear oligosaccharides, a smooth envelope of fragment ions was observed; from low to high mass there was an ordered decrease in ion abundance from both the reducing and nonreducing termini. This pattern of fragment ions was not observed for branched oligosaccharides since in these cases fragments at certain masses could not arise by single bond cleavages. Therefore, these fragments were either significantly reduced in abundance or absent as compared with identical fragments formed from linear molecules. Importantly, 200 pmol of an oligosaccharide could be derivatized, separated, and detected by mass spectrometry, allowing identification of previously unreported minor components of the IgM oligosaccharides. Therefore, this experimental strategy is particularly useful for the purification and detailed structural characterization of low abundance oligosaccharides isolated from heterogeneous biological samples.

Evaluation of alternative oil spill cleanup techniques in a Spartina alterniflora salt marsh.

Three oil spill situations which cause long-term impact were simulated in 1 m(2) salt marsh plots to evaluate the effectiveness of alternative cleanup techniques at removing oil and reducing damage to Spartina alterniflora. Cleanup techniques, implemented 18-24 h after oiling, were not effective at removing oil after sediment penetration. When oil remained on the sediment surface, flushing techniques were most effective at removal, reducing levels of added oil by 73% to 83%. The addition of dispersant to the flushing stream only slightly enhanced oil removal. Clipping of vegetation followed by sorbent pad application to sediment was moderately effective, reducing added oil by 36% to 44%. In contrast to flushing and clipping, burning increased the amount of oil in sediment by 27% to 72%. Although flushing and clipping were effective at oil removal, neither technique reduced initial damage to plants or enhanced long-term recovery. While flushed plots sustained no additional plant damage due to cleanup, clipped and burned plots sustained additional initial plant damage. Based on these results, first considerations should be given to natural tidal flushing as the means to remove oil, especially in salt marshes subject to ample tidal inundation. Although our results do not support cleanup in salt marshes with ample tidal inundation, low pressure flushing may be warranted when fuel oils or large quantities of crude oil impact salt marshes subject to reduced tidal flushing. Flushing, when warranted, should be initiated prior to oil penetration into the substrate. Clipping may be considered as a cleanup response only when heavy oil cannot be effectively removed from vegetation by flushing. Burning is not recommended because it enhances oil penetration into sediment and causes substantial initial plant damage.

Harvey A.K. Whitney lecture. The art of growing professionally.

The paths for professional development are described using past recipients of the Harvey A.K. Whitney Lecture Award as examples. Past recipients were able to improve their performance by accepting the help of others, including their families. Most of these individuals were guided by mentors who taught them how to think and supported their character. Their growth was enhanced through memberships in professional associations. As members of regional and national organizations, they were able to observe pharmacy practice outside their own communities. An attempt to grow professionally is in effect a search for excellence. One way that past recipients achieved excellence was by participating in continuing education. One of the most important factors contributing to their professional growth was their relationships with other people. Hospital pharmacists have been influenced by such persons as Harvey A.K. Whitney, Donald Francke, Donald Brodie, and Evlyn Gray Scott. Past recipients of the Harvey A.K. Whitney Lecture Award have exemplified professional growth.

Microinfusion: clinical and cost-containment concepts.

This article provides a detailed overview of the concept of intravenous drug delivery. Recognizing the limitations inherent in a gravity-controlled system and the new advantages achieved in the technology of microinfusion, defined here as the (controlled) delivery of small volumes of concentrated solutions of drugs, we have described the concepts and advantages associated with a microinfusion system. The clinical advantages to such a system are far reaching and include lower incidences of bacterial contamination, phlebitis, embolization, and fluid overload as well as more accurate delivery of drug. Since financial advantages are a prerequisite for any new system in this era of fiscal restraint, the financial considerations associated with the use of a microinfusion system are also delineated. These advantages, which range from decreases in supply costs to decreases in the overall cost of patient care, support the argument for increased utilization of microinfusion systems. Overall, it is our contention that microinfusion offers a more rational approach to the delivery of drugs in many patient populations, and expanded implementation of this challenging concept should be further explored.

Metabolic profiles of rats of different ages.

Urine samples from 6- to 31-month-old male Fischer F344 rats were analyzed using a high performance liquid chromatograph and a unique computer-based data analysis and quality control system in order to discover substances that could be used as markers in the aging process. Metabolic profiles of the organic acids from these urines yielded 42 peaks whose areas could be measured reliably. Of the 42 peaks, 10 were found by analysis of variance to vary significantly (p less than 0.05) with age. Rats from the four ages could also be distinguished using a multivariate statistic (discriminant analysis).

Enhancement by Sodium Dodecyl Sulfate of Pigment Formation in Serratia marcescens O8.

Three methods were used to determine the enhancement by sodium dodecyl sulfate (SDS) of prodigiosin formation in Serratia marcescens O8. The results of the agar disk diffusion method indicated that pigment formation was dependent upon the concentration of SDS. Diameters of the pigment zones were proportional to the logarithm of SDS concentrations of 300 to 1,500 mug/ml. When bacteria were grown in broth containing SDS from 0 to 800 mug/ml and the pigment extracts were analyzed spectrophotometrically, a similar enhancement of pigment formation was observed. Finally, these results were confirmed by high-performance liquid chromatographic analysis of the extracts. Prodigiosin appeared to be the sole component with increased synthesis. The possible mechanism of the SDS enhancement effect could be explained by an increase in negative binding sites by the association of SDS with a cell envelope component(s). These binding sites may be required for prodigiosin synthesis.

Comparison of isolation methods of urinary organic acids by high-performance liquid chromatography.

Four methods for extracting organic acids from human urine prior to analysis by high-performance liquid chromatography (HPLC) were compared. The methods were manual solvent extraction with ethyl acetate and diethyl ether, continuous solvent extraction, anion exchange with pyridinium acetate as the eluting solvent and anion exchange with hydrochloric acid as the eluting solvent. All four methods produced samples that could be analyzed by reversed-phase HPLC, but the continuous solvent extraction and anion exchange with pyridinium acetate methods gave the best reproducibilities (approximately 6% relative standard deviations). Pretreatment of the urine with barium hydroxide and hydroxylamine hydrochloride prior to anion exchange did not markedly alter the HPLC profiles.

Compatibility of penicillin and ascorbic acid injection.

The stability of Potassium Penicillin G, USP, when mixed with Ascorbic Acid Injection, USP, in 5% Dextrose Injection, USP, was studied. The change in concentration over an eight-hour period of potassium penicillin G in the admixture was determined by the hydroxylamine colorimetric assay method and the microbiological assay method. The stability of penicillin was not adversely affected by the presence of sodium ascorbate. Reports of incompatibilities between penicillin and ascorbic acid are a function of pH rather than a characteristic of the ascorbate ion. Articles reporting studies involving ascorbic acid should specify whether the work refers to the use of ascorbic acid or Ascorbic Acid Injection, USP. Confusion in the literature could be reduced by changing the official title from Ascorbic Acid Injection to Sodium Ascorbate Injection.