External duodenal fistula following closure of duodenal perforation.

AIM: Retrospective analysis of experience with management of external duodenal fistula (EDF) without using total parenteral nutrition (TPN). METHOD: Medical records of 31 patients with EDF following closure of duodenal ulcer perforation, treated over a 7-year period (1994-2001), were studied. Twenty-one patients (68%) had evidence of sepsis at presentation or during the course of treatment. None could afford TPN for optimum time. All patients received hospital-based enteral nutrition through nasojejunal tube, besides supportive medical treatment and/or surgery. Peritonitis or failure to insert nasojejunal tube for enteric alimentation led to early surgery. RESULTS: Two patients died of septicemia and multi-organ failure within 48 hours of admission. Fourteen patients (48.3%) initially received conservative treatment (Group I); six of them later required surgery. Fifteen patients (51.7%) underwent early surgery due to peritonitis (n=9) or failure to establish enteral feeding (n=6) (Group II); wound infection, intra-abdominal abscess and septicemia were more common in these patients than those in Group I. Survival rate was higher in Group I than in Group II (86% versus 40%; p< 0.05). Septicemia and gastrectomy were the independent factors associated with high mortality. CONCLUSIONS: EDF can be satisfactorily managed without TPN. Successful placement of enteral feeding line, supportive treatment and delayed surgery can achieve survival in 85% of patients. Minimum intervention is recommended when early surgery is performed in peritonitis or to establish enteral feeding line.     

Tolerance of Oocystis nephrocytioides to copper: intracellular distribution and extracellular complexation of copper

Several mechanisms have been proposed to explain how algae can tolerate heavy metals. In order to better understand the mechanisms determining metal tolerance, we examined the interaction of copper with two strains of the copper-tolerant green algae Oocystis nephrocytioides, isolated from algal communities differing only in copper exposure. The strains were cultured in chemically-defined media containing 0.04 microM Cu(total) (pCu 12.4) or 2 microM Cu(total) (pCu 10.6). Growth, photosynthesis rate, content of chlorophyll a and b, copper accumulation, its cellular distribution and ultrastructural localization, as well as the influence of algal growth on extracellular copper complexation were determined. Both strains had comparable growth and photosynthesis rates. The cellular content of both chlorophyll a and b was reduced, by roughly the same extent, at pCu 10.6 compared to pCu 12.4. Copper titration of the media indicated the production of copper-complexing ligands by O. nephrocytioides cultured at pCu 12.4 that increased with increased algal density during cell growth. No additional ligands were detected at pCu 10.6. Copper-complexing ligands had a conditional stability constant of K = 10(13) at pH 7.3. The intracellular concentration of copper in O. nephrocytioides was 80 microM at pCu 12.4 and increased to 7.5mM at pCu 10.6. The proportion of intracellular Cu accumulated increased from 8% of total Cu content at pCu 12.4 to 60% at pCu 10.6. By electron spectroscopic imaging, intracellular Cu was detected in the thylakoids and the pyrenoid of O. nephrocytioides cells. The results indicate that the tolerance of O. nephrocytioides to Cu is constitutive and does not need to be induced by previous exposure to Cu. We propose that accumulation and sequestration of Cu in thylakoids and, to a lesser extent, adsorption of copper to the algal cell surface represent the most important tolerance mechanism, for O. nephrocytioides.     

Modeling the concentration-response function of the herbicide dinoseb on Daphnia magna (survival time, reproduction) and Pseudokirchneriella subcapitata (growth rate)

Models describing dose-response relationships are becoming increasingly popular in ecotoxicology. They allow simple and thorough evaluations of toxicity test results, including inter- and extrapolations to concentrations or exposure times other than those tested. Simple parametric regression models are of particular interest because their parameters may be attributed mechanistic meanings and they can be applied without sophisticated mathematical and computational support. We recently proposed a four-parameter logistic regression model to fit the survival data of Daphnia magna under dinoseb stress. The model parameters are the maximum survival time, the minimum time required for an individual to die, effect concentration, EC(50), and a curve shape parameter. This model has now been applied to compare the lethality and reproduction toxicity of D. magna and the growth inhibition of Pseudokirchneriella subcapitata under dinoseb stress. It can be fitted adequately to all the measured data and the parameters can be attributed biological meanings in any of the three endpoints. A comparison of the modeled concentration-response functions of all three endpoints for dinoseb toxicity shows that the range of ECs with respect to both D. magna and algae is steep (a decrease of between 0.1 and 0.6 mg/L). The survival and reproduction of D. magna exhibit similar characteristic concentration-response functions and toxicities. The statistical no-effect concentration (SNEC) is 0.14 (survival) and 0.11 (reproduction)mg/L, respectively. On the other hand, algae seem to be less sensitive to dinoseb than D. magna (SNEC: 0.48 mg/L). However, further investigations of individual algae may lead to a more suitable comparison. We speculate that the four parameters of the model function can be related to specific properties of chemicals and organisms. Characterization of these properties would allow simple and appropriate estimation of the toxic effects of these chemicals.     

Mechanistic approaches for evaluating the toxicity of reactive organochlorines and epoxides in green algae

Reactive electrophilic chemicals, such as reactive organochlorine compounds or epoxides, react specifically with a broad spectrum of nucleophilic biomolecules, including proteins and DNA. Conventional toxicity tests for algae, involving the observation of growth inhibition, i.e., the inhibition of cell multiplication, after several days, yield unreliable information for risk assessment because reactive compounds hydrolyze to different extents during the exposure period. The diversity of their modes of toxic action further complicates effect assessment and calls for methods yielding additional information on the mechanisms of toxicity. One of the primary targets of reactive chemicals in cells is the tripeptide glutathione (GSH), which is important for detoxification but can also be regarded as a toxicity sensor because changes in glutathione levels indicate stress. A vital system for algae is the photosynthetic system, which is indirectly affected by reactive chemicals. The test systems developed in this study for the assessment of reactive toxicity toward algae were therefore based not only on nonspecific toxicity indicators like growth inhibition but also on indicators for disturbance of photosynthesis (inhibition of photosystem II quantum yield) and glutathione metabolism. The application of the developed test systems on Scenedesmus vacuolatus after short-term exposure of 2 h showed that these tests can be used as fast screening tests for algal toxicity and in mode-of-action-based test batteries.     

Pheochromocytoma associated with pregnancy

Pheochromocytoma associated with pregnancy is rare with potentially lethal consequences. Antepartum diagnosis improves the maternal and perinatal outcome. The issue of mode of delivery is unresolved. Its definitive treatment is surgical resection preceded by medical management. Surgical resection may be done during caesarean section as is reported in the present case.     

Practical considerations for conducting ecotoxicity test methods with manufactured nanomaterials: what have we learnt so far?

This review paper reports the consensus of a technical workshop hosted by the European network, NanoImpactNet (NIN). The workshop aimed to review the collective experience of working at the bench with manufactured nanomaterials (MNMs), and to recommend modifications to existing experimental methods and OECD protocols. Current procedures for cleaning glassware are appropriate for most MNMs, although interference with electrodes may occur. Maintaining exposure is more difficult with MNMs compared to conventional chemicals. A metal salt control is recommended for experiments with metallic MNMs that may release free metal ions. Dispersing agents should be avoided, but if they must be used, then natural or synthetic dispersing agents are possible, and dispersion controls essential. Time constraints and technology gaps indicate that full characterisation of test media during ecotoxicity tests is currently not practical. Details of electron microscopy, dark-field microscopy, a range of spectroscopic methods (EDX, XRD, XANES, EXAFS), light scattering techniques (DLS, SLS) and chromatography are discussed. The development of user-friendly software to predict particle behaviour in test media according to DLVO theory is in progress, and simple optical methods are available to estimate the settling behaviour of suspensions during experiments. However, for soil matrices such simple approaches may not be applicable. Alternatively, a Critical Body Residue approach may be taken in which body concentrations in organisms are related to effects, and toxicity thresholds derived. For microbial assays, the cell wall is a formidable barrier to MNMs and end points that rely on the test substance penetrating the cell may be insensitive. Instead assays based on the cell envelope should be developed for MNMs. In algal growth tests, the abiotic factors that promote particle aggregation in the media (e.g. ionic strength) are also important in providing nutrients, and manipulation of the media to control the dispersion may also inhibit growth. Controls to quantify shading effects, and precise details of lighting regimes, shaking or mixing should be reported in algal tests. Photosynthesis may be more sensitive than traditional growth end points for algae and plants. Tests with invertebrates should consider non-chemical toxicity from particle adherence to the organisms. The use of semi-static exposure methods with fish can reduce the logistical issues of waste water disposal and facilitate aspects of animal husbandry relevant to MMNs. There are concerns that the existing bioaccumulation tests are conceptually flawed for MNMs and that new test(s) are required. In vitro testing strategies, as exemplified by genotoxicity assays, can be modified for MNMs, but the risk of false negatives in some assays is highlighted. In conclusion, most protocols will require some modifications and recommendations are made to aid the researcher at the bench.     

Is a fall in baseline heart rate a reliable predictor of a successful single shot caudal epidural in children?

BACKGROUND: This study was designed to investigate whether a fall in heart rate (HR) with injection of local anesthetic into the caudal space can be used as a predictor of correct needle placement. METHODS: Two hundred and twenty pediatric patients undergoing infraumbilical surgery were recruited to the study. After induction of general anesthesia, baseline HR was recorded and caudal block was performed using 0.75-1 ml x kg(-1) 0.25% bupivacaine, which was injected at a rate of 1 ml x 3 s(-1). The change in HR while injecting an initial 0.2 ml x kg(-1) of drug and during total drug injection was recorded. HR reduction of > or = 3 b x min(-1) was considered a positive test for correct needle placement. The success of block was judged by HR response to skin incision, endtidal halothane concentration required for maintenance of anesthesia and postoperative pain scores. RESULTS: Caudal block was successful in 209/220 (95%) patients. Mean HR following the initial drug injection (111 +/- 17.7, P < 0.01) and entire drug injection (108.8 +/- 17.2, P < 0.01) was significantly lower than baseline (116.2 +/- 17.5). HR reduction of > or = 3 b x min(-1) was present in 190/209 and 199/209 successful block following initial drug injection and total drug injection respectively. The analysis of study data showed that a fall in HR is a predictor of successful caudal block, with a sensitivity of 90.9%, specificity of 100% and a positive predictive value of 100% after initial injection of local anesthetic. CONCLUSIONS: We conclude that decrease in HR with drug injection is a simple, objective and reliable test to predict success of caudal block.