Use of the vascular closure staple clip applier for microvascular anastomosis in free-flap surgery

We report our initial experience using the vascular closure staple clip applier (a nonpenetrating titanium clip applied in an interrupted, everting fashion) for microvascular anastomosis in free-flap surgery. In total, 153 anastomoses were performed in 87 free flaps (174 potential anastomoses) using the vascular closure stapler between October of 1997 and June of 1999. In 66 flaps, both the arterial and venous anastomosis were performed with the clip applier, whereas in 21 flaps only the venous anastomosis was performed using the clips. A total of 146 anastomoses were performed in an end-to-end fashion, and seven were performed end-to-side. Of the 87 flaps there were 53 TRAM flaps, seven bilateral TRAM, five latissimus dorsi, four gastrocnemius, three rectus abdominis, two radial forearm fibula, and four Rubens fat-pad flaps. Seventy flaps were used for breast reconstruction, seven flaps for lower limb reconstruction, four flaps for head and neck reconstruction, and six flaps for chest wall/trunk reconstruction. There were no postoperative anastomotic complications of bleeding, thrombosis, or need for revision (100 percent patency rate), with a significantly reduced time for completion of anastomoses. The clip applier is a safe, reliable method for performing microvascular anastomoses, allowing reduced operating time and possible cost savings in free-flap surgery.     

A Retrospective Evaluation of Critical Care Blood Culture Yield – Do Support Services Contribute to the “Weekend Effect”?

BackgroundThe “weekend effect” describes an increase in adverse outcomes for patients admitted at the weekend. Critical care units have moved to higher intensity working patterns to address this with some improved outcomes. However, support services have persisted with traditional working patterns. Blood cultures are an essential diagnostic tool for patients with sepsis but yield is dependent on sampling technique and processing. We therefore used blood culture yield as a surrogate for the quality of support service provision.We hypothesized that blood culture yields would be lower over the weekend as a consequence of reduced support services.MethodsWe performed a retrospective observational study examining 1575 blood culture samples in a university hospital critical care unit over a one-year period.ResultsPatients with positive cultures had, on average, higher APACHE II scores (p = 0.015), longer durations of stay (p = 0.03), required more renal replacement therapy (p<0.001) and had higher mortality (p = 0.024). Blood culture yield decreased with repeated sampling with an increased proportion of contaminants. Blood cultures were 26.7% less likely to be positive if taken at the weekend (p = 0.0402). This effect size is the equivalent to the impact of sampling before and after antibiotic administration.ConclusionsOur study demonstrates that blood culture yield is lower at the weekend. This is likely caused by delays or errors in incubation and processing, reflecting the reduced provision of support services at the weekend. Reorganization of services to address the “weekend effect” should acknowledge the interdependent nature of healthcare service delivery.     

ILCD Handbook Public Consultation Workshop

Introduction

The European Commission is supporting the development of the International Reference Life Cycle Data System (ILCD). This consists primarily of the ILCD Handbook and the ILCD Data Network. This paper gives an insight into the scientific positions of business, governments, consultants, academics, and others that were expressed at this public consultation workshop.

Workshop focus

The workshop focused on four of the topics of the main guidance documents of the ILCD Handbook: (1) general guidance on life cycle assessment (LCA); (2) guidance for generic and average life cycle inventory (LCI) data sets; (3) requirements for environmental impact assessment methods, models and indicators for LCA; and (4) review schemes for LCA.

Workshop participation

This consultation workshop was attended by more than 120 participants during the 4 days of the workshop. Representatives came from 23 countries, from both within and outside the European Union.

Workshop structure

Approximately half of the participants were from business associations or individual companies. Another 20% were governmental representatives. Others came predominantly from consultancies and academia.

Results

This public consultation workshop provided valuable inputs into the overall ILCD Handbook developments as well as for further development. This paper focuses on some of the main scientific issues that were raised.     

Accelerated hand bone mineral density loss is associated with progressive joint damage in hands and feet in recent-onset rheumatoid arthritis

Introduction

To investigate whether accelerated hand bone mineral density (BMD) loss is associated with progressive joint damage in hands and feet in the first year of rheumatoid arthritis (RA) and whether it is an independent predictor of subsequent progressive total joint damage after 4 years.

Methods

In 256 recent-onset RA patients, baseline and 1-year hand BMD was measured in metacarpals 2-4 by digital X-ray radiogrammetry. Joint damage in hands and feet were scored in random order according to the Sharp-van der Heijde method at baseline and yearly up to 4 years.

Results

68% of the patients had accelerated hand BMD loss (>-0.003 g/cm²) in the first year of RA. Hand BMD loss was associated with progressive joint damage after 1 year both in hands and feet with odds ratios (OR) (95% confidence intervals [CI]) of 5.3 (1.3-20.9) and 3.1 (1.0-9.7). In univariate analysis, hand BMD loss in the first year was a predictor of subsequent progressive total joint damage after 4 years with an OR (95% CI) of 3.1 (1.3-7.6). Multivariate analysis showed that only progressive joint damage in the first year and anti-citrullinated protein antibody positivity were independent predictors of long-term progressive joint damage.

Conclusions

In the first year of RA, accelerated hand BMD loss is associated with progressive joint damage in both hands and feet. Hand BMD loss in the first year of recent-onset RA predicts subsequent progressive total joint damage, however not independent of progressive joint damage in the first year.     

Recent oceanic long-distance dispersal and divergence in the amphi-Atlantic rain forest genus Renealmia L.f. (Zingiberaceae)

Renealmia L.f. (Zingiberaceae) is one of the few tropical plant genera with numerous species in both Africa and South America but not in Asia. Based on phylogenetic analysis of nuclear ribosomal internal transcribed spacer (ITS) and chloroplast trnL-F DNA, Renealmia is shown to be monophyletic with high branch support. Low sequence divergence found in the two genome regions (ITS: 0-2.4%; trnL-F: 0-1.9%) suggests recent diversification within the genus. Molecular divergence age estimates give further support to the recent origin of the genus and show that Renealmia has attained its amphi-Atlantic distribution by an oceanic long-distance dispersal event from Africa to South America during the Miocene or Pliocene (15.8-2.7 My ago). Some support is found for the hypothesis that speciation in neotropical Renealmia was influenced by the Andean orogeny. Speciation has been approximately simultaneous on both sides of the Atlantic, but increased taxon sampling is required to compare the speciation rates between the New World and Old World tropics.     

TFG clusters COPII‐coated transport carriers and promotes early secretory pathway organization

In mammalian cells, cargo‐laden secretory vesicles leave the endoplasmic reticulum (ER) en route to ER‐Golgi intermediate compartments (ERGIC) in a manner dependent on the COPII coat complex. We report here that COPII‐coated transport carriers traverse a submicron, TFG (Trk‐fused gene)‐enriched zone at the ER/ERGIC interface. The architecture of TFG complexes as determined by three‐dimensional electron microscopy reveals the formation of flexible, octameric cup‐like structures, which are able to self‐associate to generate larger polymers in vitro. In cells, loss of TFG function dramatically slows protein export from the ER and results in the accumulation of COPII‐coated carriers throughout the cytoplasm. Additionally, the tight association between ER and ERGIC membranes is lost in the absence of TFG. We propose that TFG functions at the ER/ERGIC interface to locally concentrate COPII‐coated transport carriers and link exit sites on the ER to ERGIC membranes. Our findings provide a new mechanism by which COPII‐coated carriers are retained near their site of formation to facilitate rapid fusion with neighboring ERGIC membranes upon uncoating, thereby promoting interorganellar cargo transport.     

An overview of malaria transmission from the perspective of Amazon Anopheles vectors

In the Americas, areas with a high risk of malaria transmission are mainly located in the Amazon Forest, which extends across nine countries. One keystone step to understanding the Plasmodium life cycle in Anopheles species from the Amazon Region is to obtain experimentally infected mosquito vectors. Several attempts to colonise Ano- pheles species have been conducted, but with only short-lived success or no success at all. In this review, we review the literature on malaria transmission from the perspective of its Amazon vectors. Currently, it is possible to develop experimental Plasmodium vivax infection of the colonised and field-captured vectors in laboratories located close to Amazonian endemic areas. We are also reviewing studies related to the immune response to P. vivax infection of Anopheles aquasalis, a coastal mosquito species. Finally, we discuss the importance of the modulation of Plasmodium infection by the vector microbiota and also consider the anopheline genomes. The establishment of experimental mosquito infections with Plasmodium falciparum, Plasmodium yoelii and Plasmodium berghei parasites that could provide interesting models for studying malaria in the Amazonian scenario is important. Understanding the molecular mechanisms involved in the development of the parasites in New World vectors is crucial in order to better determine the interaction process and vectorial competence.     

Toward an Overall Analytical Framework for the Integrated Sustainability Assessment of the Production and Supply of Raw Materials and Primary Energy Carriers

The sustainable production and supply of raw materials (“nonenergy raw materials”) and primary energy carriers (“energy raw materials”) is a core element of many policies. The natural resource base for their production and supply, and the access thereto, are limited. Moreover, raw material supply is high on environmental and social impact agendas as well. A broad, quantitative framework that supports decision makers is recommended so as to make use of raw materials and primary energy carriers more sustainably. First, this article proposes a holistic classification of raw materials and primary energy carriers. This is an essential prerequisite for developing an integrated sustainability assessment framework (ISAF). Indeed, frequently, only a subset of raw materials and primary energy carriers are considered in terms of their source, sector, or final application. Here, 85 raw materials and 30 primary energy carriers overall are identified and grouped into seven and five subgroups, respectively. Next, this article proposes a quantitative ISAF for the production and supply of raw materials and primary energy carriers, covering all the sustainability pillars. With the goal of comprehensiveness, the proposed ISAF integrates sustainability issues that have been covered and modeled in quite different quantitative frameworks: ecosystem services; classical life cycle assessment (LCA); social LCA; resource criticality assessment; and particular international concerns (e.g., conflict minerals assessment). The resulting four areas of concerns (i.e., environmental, technical, economic, and social/societal) are grouped into ten specific sustainability concerns. Finally, these concerns are quantified through 15 indicators, enabling the quantitative sustainability assessment of the production and supply of raw materials and primary energy carriers.