Little consensus in either definition or diagnosis of a lower gastro-intestinal anastomotic leak amongst colorectal surgeons.

PURPOSE: The purposes of this study were to assess the working definition of a colorectal anastomotic leak among colorectal surgeons and to survey the current approach to investigation and management of a patient with a suspected anastomotic leak. METHODS: Online survey consisting of nine questions regarding the definition, assessment and investigation of anastomotic leaks was conducted. Of the 738 eligible ACP members contacted, 210 responded (28.4%). RESULTS: Results demonstrated that 94.2% of surgeons agreed 'extravasation of contrast on enema' and 91.8% agreed 'faecal material seen in drains/from the wound' constituted a clinical leak. Only 69.2% agreed that a leak was 'intra-abdominal sepsis requiring a laparotomy', and about half agreed that radiological collections constituted a leak when either treated with antibiotics (46.6%) or with percutaneous drainage (51.4%). Serial clinical examination was the perceived most sensitive clinical feature for a leak, with 75% of surgeons ranking this in their top three choices. Surgeons radiologically confirm a leak on average in 80.2% of cases. A CT with rectal contrast for a left-sided leak was selected by 42.9% of respondents. For a right-sided/small bowel anastomosis, 44.5% selected a CT with oral contrast and 43.4% a CT with IV contrast. CONCLUSIONS: There is still significant heterogeneity between surgeons in what they define as an anastomotic leak. Most surgeons valued clinical examination as the most sensitive initial tool for leak detection; however, radiology has a major role in the confirmation of clinical leaks in colorectal patients. There is an increasing need to be able to classify and grade anastomotic leaks, both to improve the care of patients and for audit purposes.

Direct control of a computer from the human central nervous system.

We describe an invasive alternative to externally applied brain-computer interface (BCI) devices. This system requires implantation of a special electrode into the outer layers of the human neocortex. The recorded signals are transmitted to a nearby receiver and processed to drive a cursor on a computer monitor in front of the patient. Our present patient has learned to control the cursor for the production of synthetic speech and typing.

Intracellular gene transfer in action: dual transcription and multiple silencings of nuclear and mitochondrial cox2 genes in legumes.

The respiratory gene cox2, normally present in the mitochondrion, was previously shown to have been functionally transferred to the nucleus during flowering plant evolution, possibly during the diversification of legumes. To search for novel intermediate stages in the process of intracellular gene transfer and to assess the evolutionary timing and frequency of cox2 transfer, activation, and inactivation, we examined nuclear and mitochondrial (mt) cox2 presence and expression in over 25 legume genera and mt cox2 presence in 392 genera. Transfer and activation of cox2 appear to have occurred during recent legume evolution, more recently than previously inferred. Many intermediate stages of the gene transfer process are represented by cox2 genes in the studied legumes. Nine legumes contain intact copies of both nuclear and mt cox2, although transcripts could not be detected for some of these genes. Both cox2 genes are transcribed in seven legumes that are phylogenetically interspersed with species displaying only nuclear or mt cox2 expression. Inactivation of cox2 in each genome has taken place multiple times and in a variety of ways, including loss of detectable transcripts or transcript editing and partial to complete gene loss. Phylogenetic evidence shows about the same number (3-5) of separate inactivations of nuclear and mt cox2, suggesting that there is no selective advantage for a mt vs. nuclear location of cox2 in plants. The current distribution of cox2 presence and expression between the nucleus and mitochondrion in the studied legumes is probably the result of chance mutations silencing either cox2 gene.

Positron emission tomographic studies of cerebral benzodiazepine-receptor binding in chronic alcoholics.

Positron emission tomography was used with [11C]flumazenil (FMZ) and [18F]fluorodeoxyglucose to study GABA type A/benzodiazepine (GA-BA-A/BDZ) receptors and cerebral metabolic rates for glucose (1CMRg1c) in 17 male patients with severe chronic alcoholism (ALC), 8 with (ACD) and 9 without alcoholic cerebellar degeneration (non-ACD). In comparison with male normal controls of similar ages, the ALC group had significantly reduced FMZ ligand influx (K1), FMZ distribution volume (DV), and 1CMRg1c bilaterally in the medial frontal lobes, including superior frontal gyrus and rostral cingulate gyrus; the ACD group had significant reductions of K1, DV, and 1CMRg1c bilaterally in the same distribution, and also in the superior cerebellar vermis; and the non-ACD group had significant reductions of K1, DV, and 1CMRg1c bilaterally in the same regions of the frontal lobes but not in the superior cerebellar vermis. When compared with the non-ACD group, the ACD group had significant reductions of K1, and DV bilaterally in the superior cerebellar vermis. The results suggest that severe chronic alcoholism damages neurons containing GA-BA-A/BDZ receptors in the superior medial aspects of the frontal lobes, and in patients with clinical signs of ACD, neurons containing GABA-A/BDZ receptors in the superior cerebellar vermis.

Pre-operative autologous blood donations. A five-year experience in Trinidad and Tobago.

A pre-operative autologous blood donation programme was started in 1988 and made available to all doctors offering elective surgical procedures. Two hundred and seventy-seven (277) patients presented for autologous donation over a five-year period. Nine point four per cent were rejected because of low haemoglobin ( < 10.5 g/dl). The single biggest user of the programme was the Princess Elizabeth Hospital for handicapped persons. Patients undergoing orthopaedic procedures gave 50% of the donations, and ranged in age from 10 to 73 years. The oldest donor was a 73-year-old man who had an abdominal aortic aneurysm replaced. Gynaecological surgeons in the public and private sectors together provided 43.9% of donors, 3.6% of these underwent elective Caesarean Section, each donating one unit of blood at 36 weeks. Patients undergoing general surgical procedures comprised 10.4% of donors. Autologous donors contributed 1.3% of the total number of donations over this period.

Efficacy of phosphodiesterase inhibition with milrinone in combination with converting enzyme inhibitors in patients with heart failure. The Milrinone Multicenter Trials Investigators.

We describe the results of two placebo-controlled trials (MIL-1077 and MIL-1078) designed to evaluate the clinical efficacy of oral milrinone administered together with converting enzyme inhibitors to patients with congestive heart failure. Although these trials were terminated prematurely, they provide the only controlled data regarding the effect of oral milrinone on exercise capacity in patients receiving converting enzyme inhibitors. Of the 254 patients randomized, 140 completed one of the trials or reached an end point and are the basis of this report. In both trials, there was a clear trend for an increase in exercise capacity in the milrinone-treated patients (+26 +/- 8% vs. +5 +/- 7% in MIL-1077 and +11 +/- 5% vs. +2 +/- 4% in MIL-1078). Symptoms of congestive heart failure were decreased in one trial but not the other. Quality of life, as assessed by a questionnaire, was not effected in either trial. There was an increased incidence of adverse events in milrinone-treated patients. Adverse events related primarily to hypotension and vasodilation led to discontinuation of drug in 18 milrinone-treated patients vs. 1 placebo-treated patient. Milrinone had little or no proarrhythmic effect and cardiovascular deaths were distributed equally between the milrinone and placebo groups. These data suggest that when used in combination with a converting enzyme inhibitor, oral milrinone improves exercise capacity but is associated with a high incidence of adverse events that appear to be related to excessive vasodilation.

Evaluation of therapy with hyperbaric oxygen for experimental infection with Clostridium perfringens.

The effects of inoculum size and treatment delays on the efficacy of hyperbaric oxygen (HBO) were evaluated in a murine model of Clostridium perfringens myositis in which the infection was treated with an HBO regimen identical to that used for humans. The efficacies of treatment with penicillin, metronidazole, or clindamycin--alone or in combination with HBO--were also assessed. Survival was inversely related to the size of the bacterial inoculum used for challenge, and delays in treatment markedly reduced the efficacies of all single and combination regimens. When animals were challenged with > 10(8) colony-forming units, survival was significantly higher among those treated with clindamycin or metronidazole than among those treated with penicillin. HBO alone did not improve survival at any inoculum tested. However, when administered early, HBO plus metronidazole or penicillin demonstrated significant additive efficacies in animals challenged with > or = 10(9) organisms. Clindamycin was more effective at the higher inocula than penicillin, metronidazole, or HBO, and its superior efficacy was not further enhanced by adjunctive therapy with HBO.

Ophthalmic pain following cataract surgery: a comparison between local and general anaesthesia.

Ophthalmic pain following uncomplicated extracapsular cataract surgery was assessed postoperatively in 61 patients; 55% undergoing ophthalmic surgery had no pain or discomfort postoperatively, and 32% reported slight discomfort. Approximately 8% of patients reported mild pain and the remaining 5% experienced moderate to severe pain. Local anaesthesia was shown to be more comfortable postoperatively than general anaesthesia in the immediate postoperative period with both groups receiving similar amounts of postoperative analgesics.

Influence of calcium administration on the short-term hemodynamic and anti-ischemic effects of nifedipine.

This prospective study investigated whether pretreatment with intravenously administered calcium would influence the effect of nifedipine on rest hemodynamics and treadmill performance in patients with ischemic heart disease. Seventeen patients were studied after undergoing a qualifying treadmill exercise test that revealed ST segment depression indicative of ischemic heart disease. Study subjects performed three additional treadmill tests as part of the protocol. One treadmill test was obtained from each patient to provide baseline measurements without a preceding intravenous infusion and in the absence of all antianginal drugs including nifedipine; two additional exercise tests were preceded by an infusion and 10 mg of bite-and-swallow nifedipine. The infusions, administered in a randomized, double-blind, crossover fashion, consisted of either 10 ml of 10% calcium chloride (13.6 mEq) in 50 ml of 5% dextrose in water or 5% dextrose in water alone. Rest systolic blood pressure (134 +/- 4.6 mm Hg) was unchanged after placebo infusion (135 +/- 4.6 mm Hg) but decreased to 124 +/- 4.1 mm Hg (p less than 0.01) 25 min after nifedipine administration. Rest systolic blood pressure increased after calcium infusion (from 139 +/- 4.3 to 148 +/- 4.8 mm Hg, p less than 0.01) and then decreased significantly 25 min after nifedipine administration to 135 +/- 4.2 mm Hg (p less than 0.01). Despite a decrease at the time of peak nifedipine effect after either infusion, systolic blood pressure was significantly lower after administration of nifedipine alone than after administration of calcium and nifedipine (124 +/- 4.1 vs. 135 +/- 4.2 mm Hg, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Tissue disposition of boron in male Fischer rats.

Boric acid (H3BO3), an inorganic acid with widespread commercial use and consumer exposure, impairs fertility in male rodents at dose levels lower than those required to cause other adverse effects. Previous studies found a testicular lesion in adult Fischer rats fed 9000 ppm boric acid (1575 ppm boron) and slightly reduced basal serum testosterone levels. A CNS-mediated hormonal component to this lesion was suggested. Detailed data on the tissue disposition of boron in the rat, including accessory sex organs and the brain, are lacking. This study examined the tissue disposition of boron in reproductive, accessory sex organs, and other selected tissues in adult male Fischer rats fed 9000 ppm boric acid to determine if selective accumulation of boron in reproductive tissues, accessory sex organs, and/or the brain might correlate with and explain the apparent selective testicular toxicity. Adult male Fischer rats were fed 9000 ppm boric acid for up to 7 days. Animals were killed at 1, 2, 3, 4, and 7 days after the start of exposure. Plasma and excised tissues were heat-digested in acid and analyzed for boron by inductively coupled argon plasma emission spectrometry (ICAP). With the exception of adrenal glands, control boron levels in all tissues examined were below 4 micrograms/g. There was a rapid increase in plasma and tissue boron 1 day after the start of exposure (range 2- to 20-fold), with the exception of adipose tissue. With the exception of bone and adipose tissue, all soft tissues examined, including the testis, epididymis, accessory sex organs, hypothalamus, and rest of brain, appeared to reach steady-state boron levels (range 12-30 micrograms/g) by 3-4 days. Bone boron levels continued to increase up to the termination at 7 days (40-50 micrograms/g by Day 7). Bone attained the greatest concentration of boron (2- to 3-fold over plasma levels) while levels in adipose tissue were 20% of plasma levels during the 7-day exposure period. All other tissues appeared to show no appreciable accumulation of boron over plasma levels. The data suggest that neither the apparent selective testicular toxicity nor the slight CNS hormonal effect associated with boric acid exposure can be explained on the basis of selective accumulation of boron in the testis or brain/hypothalamus, respectively. Thus, the testicular toxicity is likely the result of certain biological processes that are unique to the testis and which are targets of boron exposure.

Hyperbaric oxygen as adjunctive therapy for osteomyelitis.

Mechanistically, hyperbaric oxygen (HBO) appears useful for the treatment of osteomyelitis. HBO increases the oxygen tension in infected tissue, including bone. An adequate oxygen tension is necessary for oxygen-dependent killing of organisms by the polymorphonuclear leukocytes and for fibroblast activity leading to angiogenesis and wound healing. HBO has a direct bacteriocidal or bacteriostatic effect on anaerobic organisms. In addition, HBO augments the killing of Pseudomonas aeruginosa by the aminoglycoside--tobramycin. At the University of Texas Medical Branch at Galveston, adjunctive HBO is used for the Cierny Mader stage 3B and 4B osteomyelitis.

Comparative evaluation of A-56619, A-56620, and nafcillin in the treatment of experimental Staphylococcus aureus osteomyelitis.

A rabbit model for Staphylococcus aureus osteomyelitis was used to compare the results of treatment with A-56619 and A-56620, two new aryl-fluoroquinolones, and nafcillin. A-56619 (15 mg/kg) and A-56620 (20 mg/kg), both used for 28 days of treatment, were injected subcutaneously every 12 h, and nafcillin (40 mg/kg) was injected every 6 h. After treatment, S. aureus was found on bone marrow cultures from 19 of 20 control rabbits, 6 of 20 treated with A-56619, 14 of 20 treated with A-56620, and 8 of 20 treated with nafcillin. Drug concentrations in serum and uninfected and infected bone were measured 1 h after A-56619 and A-56620 injection and 30 min after nafcillin injection in a group of rabbits that had been infected for 3 to 4 weeks. The concentrations in infected bone were similar for all three drugs and were significantly higher than in uninfected bone. The results of this study showed that A-56619 had a high rate of eradication of S. aureus from infected bone and compared favorably to nafcillin.

Gastric and oesophageal carcinogenesis: models for the identification of risk and protective factors.

Male weanling rats of the Charles River Sprague-Dawley strain were exposed to N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) in the water for 3 months at the concentration of 75 ml/litre. Other real or potential risk factors were administered, alone or in combination with MNNG. When MNNG was administered in combination with NaCl, bile acids, aspirin or BHA, forestomach tumours were enhanced. MNNG-induced tumours were inhibited by selenium or by difluoromethylornithine, an ornithine decarboxylase inhibitor. BHA alone caused forestomach tumours. When BHA was administered by dietary means or by gavage, alone or in combination with MNNG, the gavage method resulted in greater tumorigenesis than dietary exposure. This increase was associated with increased [3H]thymidine labelling of forestomach epithelium and increased hyperplasia. Oesophageal carcinogenesis induced by methylbenzylnitrosamine (MBN) was enhanced by zinc deficiency, alcohol and 13-cis-retinoic acid. Zinc deficiency also resulted in oesophageal tumours in rats exposed to the hepatocarcinogen dimethylnitrosamine. Riboflavin deficiency injured oral and oesophageal epithelium and increased sensitivity to MBN-induced oesophageal tumours.

Performance of MA-matched nonretarded and retarded children on discrimination learning and transfer-shift tasks.

The effects of the nature of the relevant dimension, response mode, imagery, and age on discrimination learning and shift performance was examined. Three age groups were used, CA 8 years-MA 8 years, CA 5 years-MA 5 years. CA 8 years-MA 5 years. The latter group learned both intradimensional and extradimensional shifts slower than did the former two groups. Subsequent analyses suggested that the reason for the slower learning in the retarded group was their greater frequency of control by dominant dimensions and/or the initial control by novel stimuli. A second finding was related to the particular procedure employed. Children were required to either press a button to indicate which of two stimuli was correct or pick up the correct stimulus. Form-relevant but not color-relevant problems were facilitated by the pick-up procedure. These findings suggest that dimensional dominance may be a consequence of the procedures employed in previous reports where children were or were not permitted to manipulate the stimuli.