Spilled Gallstones: the Source of an Enigma

Spillage of gallstones may occur in the course of laparoscopic cholecystectomy. The incidence of this mishap and its consequences are variable. Ignored by many surgeons, stone spillage may be the source of significant morbidity many years after surgery. In this report, we describe the clinical course of a patient who presented with upper abdominal pain and swelling. The past history was positive for laparoscopic cholecystectomy 15 years earlier. After excision, the swelling was found to be a pseudocyst formed around spilled gallstones during a previous cholecystectomy. Apart from postoperative wound infection, the patient recovered well and remains so. Here, we discuss the problem and provide suggestions for spillage prevention and stone retrieval once spillage occurs.     

Hypotension does not increase mortality in brain-injured patients more than it does in non-brain-injured Patients

OBJECTIVES: Hypotension increases mortality after all types of injuries. Prior studies comparing mortality of hypotensive traumatic brain injury (TBI) patients to normotensive TBI patients have implied that hypotension is particularly detrimental after TBI. It is unknown whether hypotension affects TBI patients more severely than it affects other types of patients. We hypothesized that hypotension does not increase mortality in TBI patients more than it does in non-TBI patients. METHODS: National Trauma Data Bank (1994-2002) patients aged 18 to 45 years with blunt mechanisms of injury treated at Level I and Level II centers were included. Deaths occurring before 24 hours were excluded. Logistic regression was used to measure the association between hypotension (< or =90 mm Hg) and death after adjusting for confounding variables of age, gender, comorbidities, complications, Glasgow Coma Scale score, and severity of associated injuries. Odds ratios (95% confidence interval) indicate the risk of death in hypotensive patients in each group compared with normotensive patients in the same group. RESULTS: The study population consisted of 79,478 patients (TBI, 30,742; no TBI, 48,736). Hypotension independently quadrupled the risk of death after adjusting for confounding variables (odds ratio [OR], 4.8; 95% confidence interval [CI], 4.1-5.6). However, increase in this risk associated with hypotension was the same in TBI (OR, 4.1; 95% CI, 3.5-4.9) and non-TBI patients (OR, 4.6; 95% CI, 3.4-6.0). Furthermore, the relationship between hypotension and TBI did not change with increasing head Abbreviated Injury Scale score severity. CONCLUSION: Hypotension is an independent risk factor for mortality. However, it does not increase mortality in TBI patients more than it does for non-TBI patients.     

Non‐HLA‐matched 3rd party vascular allograft in renal transplant may lead to sensitization against donor HLA

3rd party donor vessels are often used for vascular reconstruction in organ transplantation. While current practice ensures that 3rd party vessels are blood group matched, HLA matching to the non‐intended recipient is not performed. This practice potentially sensitizes the recipient and may reduce their future chance of renal transplant from a larger pool of donors. We examined our cohort of renal transplant recipients who received non‐HLA‐matched 3rd party vessels for the de‐novo development of donor‐specific HLA antibodies. Our institution's Human Tissue Authority (HTA) blood vessel registers were examined to identify stored donor vessels and their non‐intended recipients. Donor vessel HLA status was cross‐referenced with the recipient HLA status. Between 2004 and 2014, five patients were identified that received 3rd party non‐HLA‐matched vessels for vascular reconstruction during renal transplantation. Three patients (60%) subsequently developed donor‐specific HLA antibodies. These data provide evidence that use of non‐HLA‐matched stored 3rd party vascular grafts may lead to sensitization in the recipient. Where time permits, HLA matching should be performed to avoid this allogeneic response. Laboratories monitoring DSA should be aware of any patient receiving a non‐HLA‐matched 3rd party vascular graft, and recipients may benefit from increased post‐transplant immunological vigilance.     

Management of tandem occlusions in patients who receive rtPA

Journal of Thrombosis and Thrombolysis - Tandem occlusions exist in 17–32% of large vessel occlusion (LVO) strokes. A significant concern is bleeding when carotid stenting is performed in...     

Conformational dynamics of superoxide dismutase (SOD1) in osmolytes: a molecular dynamics simulation study

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease caused by the misfolding of Cu, Zn superoxide dismutase (SOD1). Several earlier studies have shown that monomeric apo SOD1 undergoes significant local unfolding dynamics and is the predecessor for aggregation. Here, we have employed atomistic molecular dynamics (MD) simulations to study the structure and dynamics of monomeric apo and holo SOD1 in water, aqueous urea and aqueous urea–TMAO (trimethylamine oxide) solutions. Loop IV (zinc-binding loop) and loop VII (electrostatic loop) of holo SOD1 are considered as functionally important loops as they are responsible for the structural stability of holo SOD1. We found larger local unfolding of loop IV and VII of apo SOD1 as compared to holo SOD1 in water. Urea induced more unfolding in holo SOD1 than apo SOD1, whereas the stabilization of both the form of SOD1 was observed in ternary solution (i.e. water/urea/TMAO solution) but the extent of stabilization was higher in holo SOD1 than apo SOD1. The partially unfolded structures of apo SOD1 in water, urea and holo SOD1 in urea were identified by the exposure of the hydrophobic cores, which are highly dynamic and these may be the initial events of aggregation in SOD1. Our simulation studies support the formation of aggregates by means of the local unfolding of monomeric apo SOD1 as compared to holo SOD1 in water.

Change in conformations of apo and holo SOD1 in water and in osmolytes in terms of configurational entropy (S).