Signet ring cells in the gastrointestinal tract: not always what it seems.

We describe two cases of pseudo-signet ring cells in gastric biopsies of otherwise asymptomatic adult patients. One male patient was diagnosed during follow-up of a previous intestinal type gastric adenocarcinoma and underwent surgery before recognition of this non-malignant entity. He suffered from a secondary anastomotic stenosis requiring dilatation. A second male patient was spared from surgery thanks to timely recognition by the pathologist and is still declared cancer-free until today. This extremely rare nonmalignant mimicker of cancerous signet ring cells, as seen in diffuse type gastric cancer can potentially mislead the clinician. The absence of any endoscopic abnormality should prompt a revision by an experienced pathologist, digestive oncologist and surgeon to avoid unnecessary interventions and morbidity.

STEC colitis mimicking acute severe colitis with life-threatening consequences: a case report.

Acute colitis is a common feature of infection with Shiga-toxin producing Escherichia coli (STEC) and can mimic acute severe ulcerative colitis. Early recognition is important as there is a risk of developing Shiga toxin-induced haemolytic uremic syndrome (STEC-HUS), defined by the triad of microangiopathic haemolytic anemia, thrombocytopenia and organ damage. In severe cases STEC-HUS can cause severe neurological complications and can be fatal. We present a patient with a medical history of refractory ulcerative colitis, where making the diagnosis of STEC-HUS was challenging since the initial clinical presentation was difficult to differentiate from a flare of ulcerative colitis. This case illustrates that STEC induced colitis can mimic acute severe ulcerative colitis. This finding is of utmost clinical importance because of the potential life-threatening complications of STEC-HUS. Therefore it should be excluded promptly in patients with acute severe ulcerative colitis by using multiplex-PCR assay on a faecal sample.

Respiratory involvement in Crohn's disease: a case report.

Inflammatory bowel disease (IBD) predominantly affects the gastro-intestinal tract. There is however a large array of extra intestinal manifestations (EIM) associated with these diseases. A lesser known EIM is pulmonary involvement, which has been first described in 1973. Since the introduction of HRCT more attention is guided towards this specific involvement. Awareness of pulmonary involvement in IBD-patients may lead to better screening, guide appropriate therapy, and ultimately result in better patient care. When untreated, serious and persisting complications, such as stenosis or strictures of the large airways, as well as bronchiectasis or bronchiolitis obliterans might occur.

Conformity and controversies in the diagnosis, staging and follow-up evaluation of canine nodal lymphoma: a systematic review of the last 15 years of published literature.

Diagnostic methods used in the initial and post-treatment evaluation of canine lymphoma are heterogeneous and can vary within countries and institutions. Accurate reporting of clinical stage and response assessment is crucial in determining the treatment efficacy and predicting prognosis. This study comprises a systematic review of all available canine multicentric lymphoma studies published over 15 years. Data concerning diagnosis, clinical stage evaluation and response assessment procedures were extracted and compared. Sixty-three studies met the eligibility criteria. Fifty-five (87.3%) studies were non-randomized prospective or retrospective studies. The survey results also expose variations in diagnostic criteria and treatment response assessment in canine multicentric lymphoma. Variations in staging procedures performed and recorded led to an unquantifiable heterogeneity among patients in and between studies, making it difficult to compare treatment efficacies. Awareness of this inconsistency of procedure and reporting may help in the design of future clinical trials.

Hydrolysis rate constants at 10-25 °C can be more than doubled by a short anaerobic pre-hydrolysis at 35 °C.

Hydrolysis is the first step of the anaerobic digestion of complex wastewater and considered as the rate limiting step especially at low temperature. Low temperature (10-25 °C) hydrolysis was investigated with and without application of a short pre-hydrolysis at 35 °C. Batch experiments were executed using cellulose and tributyrin as model substrates for carbohydrates and lipids. The results showed that the low temperature anaerobic hydrolysis rate constants increased by a factor of 1.5-10, when the short anaerobic pre-hydrolysis at 35 °C was applied. After the pre-hydrolysis phase at 35 °C and decreasing the temperature, no lag phase was observed in any case. Without the pre-hydrolysis, the lag phase for cellulose hydrolysis at 35-10 °C was 4-30 days. Tributyrin hydrolysis showed no lag phase at any temperature. The hydrolysis efficiency of cellulose increased from 40 to 62%, and from 9.6 to 40% after 9.1 days at 15 and 10 °C, respectively, when the pre-hydrolysis at 35 °C was applied. The hydrolysis efficiency of tributyrin at low temperatures with the pre-hydrolysis at 35 °C was similar to those without the pre-hydrolysis. The hydrolytic activity of the supernatant collected from the digestate after batch digestion of cellulose and tributyrin at 35 °C was higher than that of the supernatants collected from the low temperature (≤25 °C) digestates.

Pilot-scale evaluation of anammox-based mainstream nitrogen removal from municipal wastewater.

Autotrophic nitrogen removal in the mainstream wastewater treatment process is suggested to be a prerequisite of energy autarkic wastewater treatment plants (WWTP). Whilst the application of anammox-related technologies in the side-stream is at present state of the art, the feasibility of this energy-efficient process at mainstream conditions is still under development. Lower operating temperature and ammonium concentration, together with required high nitrogen removal efficiency, represent the main challenges to face in order to reach this appealing new frontier of the wastewater treatment field. In this study, we report the evaluation of the process in a plug-flow granular sludge-based pilot-scale reactor (4 m3) continuously fed with the actual effluent of the A-stage of the WWTP of Dokhaven, Rotterdam. The one-stage partial nitritation-anammox system was operated for more than 10 months at 19±1°C. Observed average N-removal and ammonium conversion rates were comparable or higher than those of conventional N-removal systems, with 182±46 and 315±33 mg-N L(-1) d(-1), respectively. Biochemical oxygen demand was also oxidized in the system with an average removal efficiency of 90%. Heterotrophic biomass grew preferentially in flocs and was efficiently washed out of the system. Throughout the experimentation, the main bottleneck was the nitritation process that resulted in nitrite-limiting conditions for the anammox conversion. Anammox bacteria were able to grow under mainstream WWTP conditions and new granules were formed and efficiently retained in the system.

Symptomatic linea arcuata hernia.

Hernias are often associated with congenital defects or incisional breakdown. Even though most of the linea arcuata hernias are asymptomatic, we present a rare case of a symptomatic linea arcuata hernia with associated internal herniation of the colon sigmoideum in a woman without previous abdominal surgery.

The prognostic relevance of tumor hypoxia markers in resected carcinoma of the gallbladder.

BACKGROUND: Intratumoral hypoxia has been suggested to drive more aggressive tumor behavior. Our aim was to define whether markers of tumor hypoxia are predictors of outcome in patients with gallbladder carcinoma. PATIENTS AND METHODS: From 1996 to 2006, 34 patients underwent resection for gallbladder carcinoma. The median follow-up was 12.6 months. Immunohistochemical stains for VEGF, HIF1α, GLUT1, GLUT3, CA9 and EGFR were performed on archival tissue. Immunohistochemical results were correlated with clinical and histopathological parameters. Cumulative overall survival (OS) rates were estimated using the Kaplan-Meier method. Multivariable Cox regression models were used to identify predictors of OS. RESULTS: The median OS was 11.9 (IQR: 3.4-22.0) months. Ubiquitous VEGF staining was observed in all gallbladder carcinomas. High (>50% of tumor cells) EGFR expression was associated with worse OS (p0.03). CA9 expression was less prevalent in poorly differentiated tumors (p0.02). GLUT3, GLUT1 and HIF1α expression were not associated with survival, but did correlate with the presence of lymph node metastasis (p0.02), tumor differentiation (p0.04) and tumor stage (p0.03) respectively. High EGFR expression, TNM stage and preoperative serum CA19.9 were retained as independent predictors of OS in multivariable analysis. CONCLUSION: In gallbladder cancer high expression of EGFR is an independent predictor of survival.

Aquatic worms eat sludge: mass balances and processing of worm faeces.

Reduction of the amount of waste sludge from waste water treatment plants (WWTPs) can be achieved with the aquatic worm Lumbriculus variegatus in a new reactor concept. In addition to reducing the amount of waste sludge, further processing of produced worm faeces and released nutrients should also be considered. This study gives the mass balances for sludge consumed by L. variegatus, showing the fate of the consumed organic material, nutrients and heavy metals associated with the sludge. A distinction is made between conversion into worm biomass, release as dissolved metabolites and what remains in the worm faeces. The results showed that 39% of the nitrogen and 12% of the phosphorus in the sludge digested by the worms are used in the formation of new worm biomass, which has potential for reuse. Experiments showed that settling of the worm faeces leads to a factor 2.5 higher solids concentration, compared to settling of waste sludge. This could lead to a 67% reduction of the volumetric load on thickening equipment. The worm reactor is expected to be most interesting for smaller WWTPs where a decrease on the volumetric load on sludge handling operations will have most impact.

Design parameters for sludge reduction in an aquatic worm reactor.

Reduction and compaction of biological waste sludge from waste water treatment plants (WWTPs) can be achieved with the aquatic worm Lumbriculus variegatus. In our reactor concept for a worm reactor, the worms are immobilised in a carrier material. The size of a worm reactor will therefore mainly be determined by the sludge consumption rate per unit of surface area. This design parameter was determined in sequencing batch experiments using sludge from a municipal WWTP. Long-term experiments using carrier materials with 300 and 350 microm mesh sizes showed surface specific consumption rates of 45 and 58 g TSS/(m(2)d), respectively. Using a 350 microm mesh will therefore result in a 29% smaller reactor compared to using a 300 microm mesh. Large differences in consumption rates were found between different sludge types, although it was not clear what caused these differences. Worm biomass growth and decay rate were determined in sequencing batch experiments. The decay rate of 0.023 d(-1) for worms in a carrier material was considerably higher than the decay rate of 0.018 d(-1) for free worms. As a result, the net worm biomass growth rate for free worms of 0.026 d(-1) was much higher than the 0.009-0.011 d(-1) for immobilised worms. Finally, the specific oxygen uptake rate of the worms was determined at 4.9 mg O(2)/(gwwd), which needs to be supplied to the worms by aeration of the water compartment in the worm reactor.

Aquatic worms grown on biosolids: biomass composition and potential applications.

The increasing production of biological waste sludge from wastewater treatment plants is a problem, because stricter legislation inhibits the use of traditional disposal methods. The use of the aquatic worm Lumbriculus variegatus can minimise sludge production. Because the worms can feed and grow on this waste sludge, valuable compounds that are present in the sludge can be recovered by the worms. This paper describes a systematic approach for finding possible applications of the produced biomass. The worm biomass mainly consists of protein and smaller fractions of fat, sugar and ash. It also contains low concentrations of heavy metals. The potential produced amount is relatively small, compared to other waste streams, and is produced decentrally. Therefore, the most promising applications are specific components of the biomass, for example specific amino acids or fatty acids. However, until the process is optimized and there is a stable supply of worms, the focus should be on simple applications, later on followed by specific applications, depending on the market demand. Worm biomass grown on clean sludges has a broader application potential, for example as consumption fish feed.

Aquatic worms eating waste sludge in a continuous system.

Aquatic worms are a biological approach to decrease the amount of biological waste sludge produced at waste water treatment plants. A new reactor concept was recently introduced in which the aquatic oligochaete Lumbriculus variegatus is immobilised in a carrier material. The current paper describes the experiments that were performed to test whether this concept could also be applied in continuous operation, for which worm growth is an important condition. This was tested for two mesh sizes of the carrier material. With an increase in mesh size from 300 to 350 microm, worm biomass growth was possible in the reactor at a rate of 0.013 d(-1) and with a yield of 0.13 g dw/g VSS digested by the worms. Mass balances over the worm reactors showed the importance of correcting for natural sludge breakdown, as the contribution of the worms to total VSS reduction was 41-71%.

The effect of operating conditions on aquatic worms eating waste sludge.

Several techniques are available for dealing with the waste sludge produced in biological waste water treatment. A biological approach uses aquatic worms to consume and partially digest the waste sludge. In our concept for a worm reactor, the worms (Lumbriculus variegatus) are immobilised in a carrier material. For correct sizing and operation of such a worm reactor, the effect of changes in dissolved oxygen (DO) concentration, ammonia concentration, temperature and light exposure were studied in sequencing batch experiments. DO concentration had an effect on both sludge consumption rate and sludge reduction efficiency. Sludge consumption rate was four times higher at DO concentrations above 8.1 mg/L, when compared to DO concentrations below 2.5 mg/L. Sludge reduction was 36 and 77% at these respective DO concentrations. The effect is most likely the result of a difference in gut residence time. An increase in unionised ammonia concentration drastically decreased the consumption rate. Ammonia is released by the worms at a rate of 0.02 mg N/mg TSS digested; therefore, replacing the effluent in the worm reactor is required to maintain a low ammonia concentration. The highest sludge consumption rates were measured at a temperature around 15 degrees C, whilst the highest TSS reduction was achieved at 10 degrees C. Not exposing the worms to light did not affect consumption or digestion rates. High temperatures (above 25 degrees C) as well as low DO concentrations (below 1 mg/L) in the worm reactor should be avoided as these lead to significant decreases in the number of worms. The main challenges for applying the worm reactor at a larger scale are the supply of oxygen to the worms and maintaining a low ammonia concentration in the worm reactor. Applying a worm reactor at a waste water treatment plant was estimated to increase the oxygen consumption and the ammonia load by 15-20% and 5% respectively.

Determinants of complications in pancreaticoduodenectomy.

AIMS: The factors determining complications after pancreaticoduodenectomy (PD) have not yet been identified clearly. This retrospective study examined, using reproducible classification systems, the type and severity of complications as well as the factors to predict them. METHODS: Between 1998 and 2005 PD was performed in 351 consecutive patients with peri-ampullary tumours. Logistic regression models were used in univariate as well as in corrected, multivariate analyses in order to identify the optimally combined factors related to the occurrence of post-operative complications. RESULTS: Post-operative complication rate was 50.7%, mortality 3.1% and re-operation rate 7.1%. Pancreatic fistula (12%) was responsible for higher mortality (9.5%; p=0.011) and re-operation (30.9%; p<0.001) rates. Hospital length of stay (LOS) was (p<0.001) longer for patients with post-operative complications (median 21.5 (range 1-128) vs. 14 (7-42) days) or pancreatic fistula (28.5 (8-128) vs. 17 (1-63) days), and related to the severity of complications. Surgeon (Odds ratio [OR] 2.03; confidence interval [CI] 1.20-3.41; p=0.008), male gender (OR 1.72; CI 1.05-2.81; p=0.032), and pre-operative hyperbilirubinaemia (OR 1.04; CI 1.001-1.08; p=0.046) were independent risk factors for post-operative complications. Neither prophylactic octreotide nor pre-operative biliary drainage improved post-operative outcome. CONCLUSION: Surgeon, male gender, and pre-operative hyperbilirubinaemia determine complication rate following PD. Pancreatic fistula is the most common complication and is associated with increased mortality, re-operation rate and LOS.

Choice of protection devices in carotid angioplasty. Two case reports.

Patient selection is of the utmost importance with all endovascular procedures. It is equally important to select the appropriate protection device during carotid angioplasty/stenting (CAS). CAS in two patients was unsuccessful due to the chosen protection device. Occlusion of the external carotid artery while deploying a Parodi Anti-Embolic-System Device (PAEC - ArteriA) resulted in cerebral ischaemia. Conversion to the Angioguard System (Cordis) made carotid angioplasty possible, but was complicated by thrombosis of the filter. In the second case it was impossible to negotiate tortuous vessels with the Angioguard system. Our experience illustrates that both devices have limitations. Choosing the wrong device may have serious consequences.

Influence of the nutrient balance on biofilm composition in a fixed film process.

An attached fungal growth has appeared in a fixed biofilm process at the waste water treatment plant of the City of Oulu, Finland. Due to the filamentous morphology of the fungi, biofilm support material is easily washed out. The appearance is believed to be the result of the unbalanced availability of nutrients, where phosphorus has been identified as the key component. Experimental work concentrated on the influence of phosphorus on the fungal growth. Bench scale experiments showed that a higher uptake of phosphorus for the removal of organic material is possible, which also resulted in a suppression of the fungal growth by bacterial biomass. The results were confirmed by experimentation in a full-scale biofilter. Addition of extra phosphoric acid to the biofilter influent resulted in a biofilm where the fungal growth is less pronounced. The fungal growth is believed to be competitive with the desired bacterial growth. It is possible to keep the fungal growth within limits by changing the conditions in favour of the bacterial growth, thus avoiding the operational problems connected with the filamentous fungi.