The use of Endo-SPONGE® in rectal anastomotic leaks: a systematic review.

BACKGROUND: The aim of this study was to assess the efficacy of an endoluminal vacuum device (Endo-SPONGE®) in the treatment of rectal anastomotic leaks. METHODS: All studies looking at endoluminal vacuum therapy with Endo-SPONGE® in the treatment of rectal anastomotic leaks were included. A comprehensive search was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was defined as the rate of total anastomotic salvage, with secondary outcomes including rate of ileostomy closure, additional transrectal closures and functional outcomes RESULTS: Sixteen studies met the inclusion criteria. There was a significant publication bias (z = 3.53, p = 0.0004). Two hundred sixty-six patients were identified. The median treatment failure rate was 11.8% (range 0-44%), with random effects model of 0.17 (95% CI 0.11-0.22). There was improvement with early therapy start (OR 3.48) and negative correlation with neoadjuvant radiotherapy (OR 0.56). Fifty-one percent of all diverting stomas were closed at the end of treatment period and 12.8% of patients required an additional trans-rectal closure of the abscess cavity. CONCLUSIONS: Endo-SPONGE® seems to be a useful method of rectal anastomotic leak treatment in selected group of patients; however, the quality of available data is poor and it is impossible to draw a final conclusion. There is unexpected high rate of permanent ileostomy. There is a need for further assessment of this therapy with well-designed randomised or cohort studies.

Subtotal cholecystectomy: is it a safe option for difficult gall bladders?

INTRODUCTION: Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepatocystic triangle. This study aimed to evaluate the safety profile of STC. METHODS: We retrospectively reviewed all patients who had STC at our unit between February 2009 and August 2019. STC was divided into two types, reconstituting (R-STC) and fenestrating (F-STC), depending on whether the gall bladder remnant was closed or left open. Patients who had cholecystectomy for gall bladder malignancy or as part of another operation were excluded from the study. RESULTS: A total of 5,664 patients underwent cholecystectomy during the study period. Of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall postoperative complication rate (45.4%, 44 cases). No patient suffered iatrogenic bile duct injury. Nineteen patients (19.6%) suffered postoperative bile leak. This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases; p=0.04). There was no significant difference in rate of bile leak or other complications between R-STC and F-STC types. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90 days post STC. CONCLUSIONS: STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the perioperative morbidity associated with STC is relatively high. Surgeons should be aware of the risks of STC and take appropriate steps to minimise them.

Hydrodynamic treatment of wastewater effluent flocs for improved disinfection.

Hydrodynamic forces generated by an orifice plate under low pressure were examined as a means of disrupting flocs, in order to improve disinfection of treated wastewater effluents. Changes in cavitation conditions were found to have little impact on the extent of particle breakage in this experimental setup. The rate of strain (flow rate divided by the hole radius cubed), however, was found to be the best predictor of floc breakage. Floc breakage was not affected by changes in floc concentration, but was very sensitive to differences between flocs collected from different sources. Larger flocs (90 to 106 microm) were broken apart to a greater extent than smaller ones (53 to 63 microm). Hydrodynamic treatment decreased the viability of bacteria associated with large flocs, and also increased the ultraviolet dose response by up to one log unit (i.e., a factor of ten). Subjecting final effluent wastewaters to hydrodynamic treatment, therefore, provides a treatment strategy for conditions in which the presence of flocs limits the level of disinfection that can be achieved.

Removal of chromium using Rhizobium leguminosarum.

The chromium (Cr(III) and Cr(VI)) removal capability of Rhizobium leguminosarum was checked by estimating the amount of chromium in the medium before and after inoculation. To determine the efficiency of R. leguminosarum in removal of chromium, the influence of physical and chemical parameters such as temperature, pH and different concentrations (0.1-1.0 mM) of trivalent (Cr(III)) and hexavalent (Cr(VI)) chromium were studied. The chromium removal in aqueous solution by different size of active and inactivated biomass and immobilized cells of R. leguminosarum in a packed-bed column was also carried out. Results showed that in a medium containing up to 0.5 mM concentration of both Cr(III) and Cr(VI), R. leguminosarum showed optimal growth. The maximum chromium removal was at pH 7.0 and 35°C. Active biomass removed 84.4 ± 3.6% of Cr(III) and 77.3 ± 4.3% of Cr(VI) in 24 h of incubation time. However, inactivated biomass removed maximum chromium after 36 h of incubation. Immobilized bacterial cells in a packed-bed column removed 86.4 ± 1.7% of Cr(III) and 83.8 ± 2.2% of Cr(VI) in 16 and 20 h of incubation time, respectively.

Performance and fouling characteristics of a submerged anaerobic membrane bioreactor for kraft evaporator condensate treatment.

Submerged anaerobic membrane bioreactor (SAnMBR) technology was studied for kraft evaporator condensate treatment at 37 +/- 1 degrees C over a period of 9 months. Under tested organic loading rates of 1-24 kg COD/m3/day, a chemical oxygen demand (COD) removal efficiency of 93-99% was achieved with a methane production rate of 0.35 +/- 0.05 L methane/g COD removed and a methane content of 80-90% in produced biogas. Bubbling of recycled biogas was effective for in-situ membrane cleaning, depending on the biogas sparging rate used. The membrane critical flux increased and the membrane fouling rate decreased with an increase in the biogas sparging rate. The scanning electron microscopy images showed membrane pore clogging was not significant and sludge cake formation on the membrane surface was the dominant mechanism of membrane fouling. The results suggest that the SAnMBR is a promising technology for energy recovery from kraft evaporator condensate.

Development of random amplified polymorphic DNA markers for tropical tasar silkworm Antheraea mylitta.

Antheraea mylitta (Drury) is a tropical tasar-silk producing insect. Its populations occupying different ecological and geographical regions show a certain degree of phenotypic variability, for which they are known as "eco-races." The eco-races are exploited for tasar silk production, and they are classified on the basis of their geographical distribution and morphology, which is often misleading when their systematic position is considered. To understand the genetic variability among the different eco-races, we used the random amplified polymorphic DNA (RAPD) method. Eighty random decamer primers were taken for RAPD amplifications. In total, 415 reproducible bands were used to generate a distance matrix, and for the subsequent clustering with unweighted pair-group method with arithmetic average. The number of polymorphic bands detected by each primer ranged from 5 to 24, with a mean value of 14.1 per primer. Percentage polymorphism was 81.9, and genetic distance values ranged from a minimum of 0.0108 between Modal and Nalia eco-races to a maximum of 0.0244 between Modal and Andhra local. The RAPD profiles obtained using A14, BC07, and C17 primers substantially differentiate all 10 commercially important eco-races, and the phylogenetic tree obtained from the data closely follows their geographical separations.

Molecular phylogeny of silk-producing insects based on 16S ribosomal RNA and cytochrome oxidase subunit I genes.

We have examined the molecular-phylogenetic relationships between nonmulberry and mulberry silkworm species that belong to the families Saturniidae, Bombycidae and Lasiocampidae using 16S ribosomal RNA (16S rRNA) and cytochrome oxidase subunit I (coxI) gene sequences. Aligned nucleotide sequences of 16S rRNA and coxI from 14 silk-producing species were used for construction of phylogenetic trees by maximum likelihood and maximum parsimony methods. The tree topology on the basis of 16S rRNA supports monophyly for members of Saturniidae and Bombycidae. Weighted parsimony analysis weighted towards transversions relative to transitions (ts, tv4) for coxI resulted in more robust bootstrap support over unweighted parsimony and favours the 16S rRNA tree topology. Combined analysis reflected clear biogeographic pattern, and agrees with morphological and cytological data.

Postobstructive pulmonary edema following anesthesia.

Pulmonary edema developing after the relief of upper airway obstruction has been reported in association with a diversity of etiologic factors, including hanging, strangulation, tumors, foreign bodies, goiter, and laryngospasm. Since 1977, 18 cases of adults with postobstructive pulmonary edema associated with anesthesia have been reported. A case is presented of a healthy 20-year-old male who developed pulmonary edema following two episodes of acute upper airway obstruction associated with general anesthesia. Postanesthetic laryngospasm has been implicated as the most frequent cause of this syndrome in adults. Risk factors for the development of upper airway obstruction have been identified in the majority of these cases. A heightened awareness among anesthesiologists of this poorly recognized and hence often perplexing syndrome may help reduce the occurrence and facilitate the treatment of this potential complication of perioperative airway management.

Sludge properties and their effects on membrane fouling in submerged anaerobic membrane bioreactors (SAnMBRs).

Two submerged anaerobic membrane bioreactors (SAnMBRs) (thermophilic vs. mesophilic) were operated for a period of 3.5 months with kraft evaporator condensate at a feed chemical oxygen demand of 10,000 mg/L. The results show that the filtration behavior of the two systems was significantly different. The filtration resistance in the thermophilic SAnMBR was about 5-10 times higher than that of the mesophilic system when operated under similar hydrodynamic conditions. Comparison of sludge properties and cake layer structure from the two systems was made to elucidate major factors governing the different filtration characteristics. There were more soluble microbial products (SMP) and biopolymer clusters (BPC) produced and a larger portion of fine flocs (<15 microm) in the thermophilic SAnMBR. Analysis of bound extracellular polymeric substances (EPS) showed that the thermophilic sludge had a higher protein/polysaccharide ratio in EPS, as compared to that in the mesophilic sludge. A series of analyses, including Fourier transform infrared (FTIR) spectroscopy, energy dispersive X-ray spectroscopy (EDX), confocal laser scanning microscopy (CLSM), scanning electron microscopy (SEM), atomic force microscopy (AFM) and particle size analyzer showed that the cake layer formed in the thermophilic SAnMBR contained higher levels of both organic and inorganic foulants, smaller particle sizes, and especially, a denser and more compact sludge cake structure. These results indicate that floc size, SMP, BPC, bound EPS as well as cake layer structure are the major factors governing membrane fouling in SAnMBR systems.

Purification and characterization of tannase from Paecilomyces variotii: hydrolysis of tannic acid using immobilized tannase.

An extracellular tannase (tannin acyl hydrolase) was isolated from Paecilomyces variotii and purified from cell-free culture filtrate using ammonium sulfate precipitation followed by ion exchange and gel filtration chromatography. Fractional precipitation of the culture filtrate with ammonium sulfate yielded 78.7% with 13.6-folds purification, and diethylaminoethyl-cellulose column chromatography and gel filtration showed 19.4-folds and 30.5-folds purifications, respectively. Molecular mass of tannase was found 149.8 kDa through native polyacrylamide gel electrophoresis (PAGE) analysis. Sodium dodecyl sulphate-PAGE revealed that the purified tannase was a monomeric enzyme with a molecular mass of 45 kDa. Temperature of 30 to 50 degrees C and pH of 5.0 to 7.0 were optimum for tannase activity and stability. Tannase immobilized on alginate beads could hydrolyze tannic acid even after extensive reuse and retained about 85% of the initial activity. Thin layer chromatography, high performance liquid chromatography, and (1)H-nuclear magnetic resonance spectral analysis confirmed that gallic acid was formed as a byproduct during hydrolysis of tannic acid.

Effect of dissolved oxygen regime on growth dynamics of Pseudomonas spp during benzene degradation.

We investigated the effect of different oxygen regimes on growth patterns of Pseudomonas spp. during benzene degradation in microcosm batch studies. Benzene degradation was induced by limiting oxygen available for microbial activity, which consists of three initial-dissolved oxygen (DO) levels of oxic, hypoxic, and anoxic conditions. Batch experiments were performed for cell growth and benzene degradation by inoculating three strains of Pseudomonas spp. (Pseudomonas aeruginosa, Pseudomonas fluorescens, Pseudomonas putida) in mineral salt medium containing aqueous benzene. Results showed that all strains were capable to grow and degrade benzene under all oxygen regimes but in a different manner. The highest cell growth of P. aeruginosa and P. fluorescens was achieved under oxic and anoxic condition, respectively, but there was no substantial difference on benzene degradation between the oxygen treatments with about 25% reduction for both strains. P. putida showed a facultative process for both cell growth and benzene degradation. This reveals that care should be taken in selection of microorganisms with regard to environmental studies since they exhibit different responses for given environmental conditions such as DO levels.

The impact of differential expression of extracellular matrix metalloproteinase inducer, matrix metalloproteinase-2, tissue inhibitor of matrix metalloproteinase-2 and PDGF-AA on the chronicity of venous leg ulcers.

INTRODUCTION: Alteration in the expression of extracellular matrix metalloproteinase inducer (EMMPRIN), matrix metalloproteinase-2 (MMP-2), tissue inhibitors of matrix metalloproteinases (TIMP-2) and platelet derived growth factor (PDGF-AA) may contribute to poor healing in venous leg ulcers. AIM: The aim of this study is to determine the expression of EMMPRIN, MMP-2, TIMP-2 and PDGF-AA in the ulcer exudates and perivascular tissue of healing and non-healing chronic venous ulcers. PATIENTS, MATERIALS AND METHODS: Forty patients with chronic venous ulcers were included in this study, with a mean age of 60 years. Eleven patients were males and 29 were females. All patients had normal ankle brachial index and a venous ulcer of at least 8 weeks duration. Immuno-histochemistry using monoclonal antibodies to PDGF-AA, MMP-2, TIMP-2 and EMMPRIN was carried out on paraffin embedded punch biopsy skin specimens from the ulcer edge. Enzyme linked immunosorbent assay for PDGF, MMP-2 and TIMP-2 were carried out on wound fluids collected from patients. The ulcer size and character at the initial assessment and after 8 weeks were assessed to determine the status of ulcer healing. RESULTS: No significant difference was seen in the expression of TIMP-2, MMP-2 and EMMPRIN between the two groups. However, in the non-healing group high levels of MMP-2 and low levels of TIMP-2 in the wound fluid suggest a strong correlation of these two markers in the state of healing. Analysis of wound fluid by ELISA demonstrated high PDGF-AA in the healing group (p = 0.021). Significantly increased levels of PDGF-AA (p<0001) was noted in the perivascular area on immuno-histochemistry of healing ulcers. These data suggest that PDGF-AA plays an important role in healing of venous ulcers. CONCLUSION: Non-healing venous ulcers are associated with greater activity MMP-2 activity. The ratio of MMPs to their inhibitors TIMPs, dictate the rate of healing of the ulcers. PDGF-AA activity is associated with ulcer healing, though the mechanism is unclear. EMMPRIN expression in chronic venous ulcers probably parallels the chronicity of the condition rather than propagate it. However, further studies with larger samples are needed.

Haemoglobin A1c (HbA1C) in non-diabetic and diabetic vascular patients. Is HbA1C an independent risk factor and predictor of adverse outcome?

BACKGROUND: Plasma Haemoglobin A1c (HbA1c) reflects ambient mean glycaemia over a 2-3 months period. Reports indicate that patients, with and without diabetes, with an elevated HbA1c have an increased risk of adverse outcome following surgical intervention. Our aim was to determine whether elevated plasma HbA1c level was associated with increased postoperative morbidity and mortality in patients undergoing vascular surgical procedures. METHODS: Plasma HbA1c was measured prospectively in 165 consecutive patients undergoing emergency and elective vascular surgical procedures over a 6-month period. Patients were categorized into four groups depending on whether their plasma HbA1c was < or =6%, 6.1-7%, 7.1-8% or >8% and clinical data was entered into a prospectively maintained database. Patients were also classified by diabetic status with suboptimal HbA1c in a patient without diabetes being >6 to < or =7% and suboptimal HbA1c in a patient with diabetes being >7%. Patients with plasma HbA1c >7% were reclassified as having undiagnosed diabetes mellitus. Composite primary endpoints were all cause 30-day morbidity and mortality and all cause 6-month mortality. Composite secondary endpoints were procedure specific complications, adverse cardiac events, stroke, infection and mean length of hospital stay. RESULTS: Of the 165 patients studied, 43 (26.1%) had diabetes and the remaining 122 (73.9%) did not. The mean age was 72 years and 59% were male. Suboptimal HbA1c levels were found in 58% patients without diabetes and in 51% patients with diabetes. In patients without diabetes those with suboptimal HbA1c levels (6-7%) had a significantly higher incidence of overall 30-day morbidity compared to patients with HbA1c levels < or =6% (56.5 vs 15.7%, p<0.001). Similarly, for patients with diabetes those with suboptimal HbA1c levels (HbA1c >7%) had a significantly higher incidence of 30-day morbidity compared to those with HbA1c levels < or =7% (59.1% vs 19%, p=0.018). Multivariate analysis revealed that a plasma HbA1c level of >6 to < or =7% was a significant independent predictor of overall 30-day morbidity in patients without diabetes undergoing vascular surgical procedures. No difference in mortality, composite secondary endpoints, procedure specific complications, stroke or mean length of hospital stay was observed between any of the groups in the study. CONCLUSION: Suboptimal HbA1c levels may hold prognostic significance in patients without diabetes undergoing vascular surgery.

The influence of subintimal angioplasty on level of amputation and limb salvage rates in lower limb critical ischaemia: a 15-year experience.

OBJECTIVES: The aim of this study is to assess the influence of subintimal angioplasty (SIA) on lower limb amputation rate and level in critically ischaemic limbs. METHODS: Between January 1989 and March 2004, 1268 patients were admitted for treatment of lower limb critical ischaemia. Eight hundred and twenty-nine patients underwent revascularisation (bypass 671 and angioplasty 158), while 439 patients had primary amputations. A retrospective analysis of a prospectively maintained vascular registry was performed. Patients were divided into two groups, those who were admitted prior to the availability of subintimal angioplasty and those treated post-introduction of angioplasty. The two groups were compared with regards to age, sex, diabetes mellitus, ASA grade, Rutherford classification and level of disease. Outcome was assessed by the limb salvage rate, 30-day morbidity and mortality, and length of hospital stay. RESULTS: The average number of revascularisation increased with the introduction of subintimal angioplasty, from 53 to 96 per year (p<0.001). The overall limb salvage rate increased significantly from 42 to 70% (p<0.001). The cumulative limb salvage rate following revascularisation rose from 72 to 86% (p<0.001). The level of amputation (AKA:BKA) did not vary significantly. Thirty-day morbidity, mortality and length of hospital stay were significantly lower in the post-angioplasty group. CONCLUSIONS: Technical advances have resulted in a steadying of amputation numbers despite an ageing population.

Modeling of growth kinetics for Pseudomonas spp. during benzene degradation.

A modeling study was conducted on growth kinetics of three different strains of Pseudomonas spp. (Pseudomonas aeruginosa, Pseudomonas fluorescens, Pseudomonas putida) during benzene degradation to determine optimum substrate concentrations for most efficient biodegradation. Batch tests were performed for eight different initial substrate concentrations to observe cell growth and associated substrate degradation using benzene-adapted cells. Kinetic parameters of both inhibitory (Haldane-Andrews, Aiba-Edwards) and noninhibitory (Monod) models were fitted to the relationship between specific growth rate and substrate concentration obtained from the growth curves. Results showed that half-saturation constant of P. fluorescens was the highest among the three strains, indicating that this strain could grow well at high concentration, while P. putida could grow best at low concentration. The inhibition constant of P. aeruginosa was the highest, implying that it could tolerate high benzene concentration and therefore could grow at a wider concentration range. Estimated specific growth rate of P. putida was lower, but half-saturation constant was higher than those from literature study due to high substrate concentration range used in this study. These two kinetic parameters resulted in substantial difference between Monod- and Haldane-type models, indicating that distinction should be made in applying those models.

Succinylcholine does not increase serum potassium levels in patients with acutely ruptured cerebral aneurysms.

Succinylcholine-induced hyperkalemia has been reported to occur in many neurological disorders including subarachnoid hemorrhage. The purpose of this study was to compare the effect of succinylcholine on serum potassium levels in patients with ruptured cerebral aneurysms undergoing either early (less than or equal to 4 days; n = 14) or delayed (5-16 days; n = 20) surgery. Thirty-four patients were classified according to the number of days from subarachnoid hemorrhage to surgery. Arterial serum potassium levels were measured after induction of anesthesia but before succinylcholine, and 1, 5, and 10 min after the administration of succinylcholine. The electrocardiogram was continuously monitored. The mean ( +/- SD) increase in serum potassium level of 0.4 +/- 0.2 mmol/L occurred at 10 min but was not statistically significant, nor was there any statistically significant difference in serum potassium levels related to time between subarachnoid hemorrhage and administration of succinylcholine. We found no evidence of succinylcholine-induced hyperkalemia in patients undergoing either early or delayed cerebral aneurysm surgery.

Prospective randomized controlled trial: conventional versus powered phlebectomy.

OBJECTIVES: Transilluminated powered phlebectomy (TriVex) is a new surgical technique that uses tumescent dissection, transillumination, and powered phlebectomy. The purpose of this study was to compare TriVex with conventional varicose vein surgery in terms of pain, cosmesis, recurrence, complications, and operating time. METHODS: One hundred eighty-eight limbs in 141 patients (33 men, 108 women; mean age, 42.5 years) with varicose veins were randomised to conventional (n = 100) or TriVex (n = 88). Exclusion criteria were venous ulceration or deep venous disease. Varicosities were graded with CEAP and clinical assessment (grades 1-3), and were similar in both groups. Randomization was single blinded. Long or short saphenous vein ligation or stripping was performed as indicated with duplex scanning. Operative time was from skin incision to leg bandaging. Phlebectomy was performed with conventional stab avulsions or TriVex. Patients completed assessment forms preoperatively and postoperatively (2, 6, 26, 52 weeks), and this was supplemented with physician clinical evaluation. Pain was assessed with visual analog score. RESULTS: There was a significant difference in the number of incisions for phlebectomy in the two groups (conventional, n = 29; TriVex, n = 5; P <.0001). TriVex was faster in the grade 3 (extensive) group, but this did not reach statistical significance. There was no difference in mean postoperative pain score over 8 days in the two groups (P =.4624). At 2 weeks there was no significant difference between the groups with regard to bruising (P =.77), cellulitis (P =.33), and numbness (P =.33). At 6 weeks there was no significant difference between the groups with regard to nerve injury (P =.97), residual veins (P =.79), cosmetic score (P =.837), and overall satisfaction (P =.878). At 6 and 12 months, there was no significant difference in cosmesis (P =.955, P =.088, respectively) or recurrence (P =.27, P =.11, respectively). CONCLUSIONS: TriVex is a safe and effective method for excision of varicosities and compares well, after a learning curve, with conventional surgery in regard to complications and recurrence. It has the advantage of a trend toward reduced operating time in extensive varicosities, and significantly fewer incisions, although there was no perceived difference in cosmesis during follow-up.