Superior mesenteric artery syndrome: a single centre experience of laparoscopic duodenojejunostomy as the operation of choice.

INTRODUCTION The superior mesenteric artery (SMA) syndrome, or Wilkie's syndrome, is a rare cause of postprandial epigastric pain, vomiting and weight loss caused by compression of the third part of the duodenum as it passes beneath the proximal superior mesenteric artery. The syndrome may be precipitated by sudden weight loss secondary to other pathologies, such as trauma, malignancy or eating disorders. Diagnosis is confirmed by angiography, which reveals a reduced aorto-SMA angle and distance, and contrast studies showing duodenal obstruction. Conservative management aims to increase intra-abdominal fat by dietary manipulation and thereby increase the angle between the SMA and aorta. Where surgery is indicated, division of the ligament of Treitz, anterior transposition of the third part of the duodenum and duodenojejunostomy have been described. METHODS We present four cases of SMA syndrome where the intention of treatment was laparoscopic duodenojejunostomy. The procedure was completed successfully in three patients, who recovered quickly with no short-term complications. A fourth patient underwent open gastrojejunostomy (complicated by an anastomotic bleed) when dense adhesions prevented duodenojejunostomy. CONCLUSIONS The superior mesenteric artery syndrome should be considered in patients with epigastric pain, prolonged vomiting and weight loss. Laparoscopic duodenojejunostomy is a safe and effective operation for management of the syndrome. A multi-speciality team approach including gastrointestinal, vascular and radiological specialists should be invoked in the management of these patients.

The Birmingham experience of high-pressure methylene blue dye test during primary and revisional bariatric surgery: A retrospective cohort study.

INTRODUCTION: Leak following bariatric surgery continues to be associated with morbidity and rarely mortality. With improvement in surgical techniques and stapler design, leak rates have reduced drastically. Intra-operative high pressure Methylene blue leak test (HPMB) is one of the techniques employed to confirm integrity of anastomoses and staple lines. Despite this, evidence for its use remains limited. We evaluated the role of HPMB in detecting and preventing leaks. METHODS: A retrospective cohort of consecutive patients who underwent primary or revisional Laparoscopic Sleeve Gastrectomy (SG) or Laparoscopic Roux-en-Y Gastric bypass (RYGB) under the care of five surgeons in three centres across Birmingham, UK, between 2012 and 2016 were assessed. All patients had routine HPMB at the end of the procedure. Demographics, HPMB positivity, and post operative leaks were recorded. RESULTS: 924 patients underwent bariatric surgery: 696(75.3%) RYGB, and 225(24.3%) SG. 85(9.2%) were revisional procedures. Two HPMB were positive, which necessitated staple or suture line reinforcement with sutures intra-operatively. The patients had an uneventful recovery. 5 patients had postoperative leaks, all of whom had negative intraoperative HPMB: 3 SG patients; and 2 RYGB patients (gastro-jejunostomy anastomotic leaks). There was no statistically significant relationship between positive HPMB and anastomotic leak (Fishers exact test; p = 1). CONCLUSION: Despite routine use of methylene blue dye test in 924 patients, there were only two positive tests. Whilst HPMB may demonstrate technical failure, this study suggests that there is no role for its routine use in primary bariatric surgery. Discontinuation of this practice would reduce risk of anaphylaxis to the dye, cost, and intra-operative time.

Biophysical studies of the cellular elements of the rabbit carotid body.

The carotid body is a major sensor of oxygen partial pressure in the arterial blood, and plays a role in the control of respiration. Despite extensive investigation of the structure, the cellular basis of the transduction mechanism remains poorly understood. We have developed a preparation of freshly dissociated cells from the rabbit carotid body, in which two cell types may be identified using morphological criteria. The preparation allows application of the patch clamp technique to characterize the properties of the cells which have otherwise proved difficult to study in situ. Carotid bodies of rabbits were dissociated using a combination of enzymatic and mechanical procedures. The dissociated preparation obtained consisted of clusters of spherical or ovoid cells of 12-15 microns in diameter and a distinct population of spherical cells of 8-10 microns diameter. Electron microscopic techniques were used to identify the cells present in the preparation. Again two populations of cells could be distinguished. A population of cells 10-12 microns in diameter, often found in clusters, possessed the dense-cored vesicles characteristic of Type I cells, while a population of smaller cells (diameter 5-7 microns) had peripherally condensed nuclear chromatin and fine cytoplasmic surface extensions characteristic of Type II cells. Patch clamp study of the cells showed that they represent two electrophysiologically distinct populations. The larger cells, corresponding to Type I cells, were found to be excitable, generating fast, sodium-dependent action potentials that were recorded both in the cell attached and whole cell recording configurations. The smaller Type II cells did not generate action potentials. Voltage clamp study of Type I cells allowed definition of a range of voltage-gated currents. These included an inactivating, tetrodotoxin-sensitive inward sodium current, a high threshold sustained inward calcium current, and outward potassium currents. A component of the outward current showed a dependence on voltage-gated calcium entry, and was blocked by cobalt or cadmium. Of the calcium-dependent current, a component was sensitive to apamin, and the remaining current was blocked by tetraethylammonium. Type II cells showed only a high threshold outward potassium current. These studies have thus revealed an electrophysiological differentiation that parallels the morphological differentiation of the cells of the carotid body. The Type I cell is essentially neuron-like in its properties, while the Type II cell appears to have properties resembling those of glial elements elsewhere in the nervous system.(ABSTRACT TRUNCATED AT 400 WORDS)

Characterization of opioid receptors in the cat carotid body involved in chemosensory depression in vivo.

The effects of selective opioid receptor agonists and antagonists on neural discharge recorded from carotid body arterial chemoreceptors in vivo were studied in anaesthetized cats. Mean ID50 values were determined for each agonist and used to assess chemodepressant potency on intracarotid (i.c.) injection in animals artificially ventilated with air. [Met]enkephalin, [Leu]enkephalin, [D-Ala2, D-Leu5]enkephalin and [D-Pen2, D-Pen5]enkephalin were more potent chemodepressants than [D-Ala2, Me-Phe4, Gly-ol5]enkephalin, dynorphin (1-8) or ethylketocyclazocine; morphiceptin (mu-agonist) was inactive. The rank order of potency was compatible with the involvement of delta-opioid receptors in opioid-induced depression of chemosensory discharge. ICI 154129, a delta-opioid receptor antagonist, was used in fairly high doses and caused reversible dose-related antagonism of chemodepression induced by [Met]enkephalin. It also antagonized depression caused by single doses of [Leu]enkephalin, [D-Ala2, D-Leu5]enkephalin, [D-Ala2, Me-Phe4, Gly-ol5]enkephalin or dynorphin (1-8). ICI 174864, a more potent and selective delta-opioid receptor antagonist, also antagonized chemodepression induced by [Met]enkephalin or by the selective delta-receptor agonist [D-Pen2, D-Pen5]enkephalin. Comparison of background or 'spontaneous' chemosensory discharge during the 30 min periods immediately before and after injecting ICI 174864 (0.1-0.2 mg kg-1 i.c.) showed a significant increase in discharge in one experiment, but in four others discharge was either unaffected or decreased after the antagonist, which argues against a toxic depression of chemosensors by endogenous opioids under resting conditions in our preparation. Sensitivity of the carotid chemoreceptors to hypoxia (ventilating with 10% O2) was increased significantly after ICI 174864, which could be taken as evidence that endogenous opioids depress chemosensitivity during hypoxia. In contrast, responsiveness to hypercapnia was reduced after the antagonist, implying that endogenous opioids may potentiate chemoreceptor sensitivity during hypercapnia. The results obtained using 'selective' agonists and antagonists provide evidence that depression of chemosensory discharge caused by injected opioids involves a delta type of opioid receptor within the cat carotid body. Endogenous opioids may modulate arterial chemoreceptor sensitivity to physiological stimuli such as hypoxia and hypercapnia.

Effects of the antagonists MDL 72222 and ketanserin on responses of cat carotid body chemoreceptors to 5-hydroxytryptamine.

The effects of intracarotid (i.c.) injections of 5-hydroxytryptamine (5-HT; 1-50 micrograms) on carotid chemoreceptor activity recorded from the carotid sinus nerve have been studied in anaesthetized cats. Three separate components in the complex response of the chemoreceptors to injected 5-HT were identified. Firstly, a transient burst of activity was obtained during the injection period in 56% of the recordings. Secondly, in all the recordings a period of chemodepression commenced a few seconds after completing the injection and was usually dose-related. Thirdly, a delayed longer-lasting chemoexcitation occurred in many experiments, concomitant with a fall in systemic blood pressure. The neuronal 5-HT receptor antagonist MDL 72222 (10-100 micrograms kg-1, i.c.) virtually abolished the transient chemoexcitation evoked during 5-HT injections and also significantly increased the mean ID50 for 5-HT-induced chemodepression; in 37% of recordings 5-HT caused a dose-related chemoexcitation after the high dose of MDL 72222. Neither the delayed chemoexcitation nor the hypotension caused by 5-HT were much affected by the antagonist. MDL 72222 itself had a biphasic effect on chemosensory discharge, causing depression followed by a delayed excitation. The 5-HT2-receptor antagonist ketanserin (100 micrograms kg-1, i.c.) had no appreciable effect on the transient chemoexcitation evoked during 5-HT injections and caused a slight but significant increase in the mean ID50 for 5-HT-induced chemodepression. The delayed chemoexcitation and accompanying hypotension associated with 5-HT were both substantially reduced or abolished by the antagonist. Ketanserin itself caused a short-lasting period of chemoexcitation. All the effects of injected 5-HT on chemosensory discharge could be abolished by the combination of MDL 72222 and ketanserin (100 micrograms kg-1, i.c.). Neither MDL 72222 nor ketanserin had any significant effect upon the response of the carotid chemoreceptors to hypoxia. The rate at which discharge increased, and also the steady-state discharge before and during hypoxia, were unaffected by the antagonists, alone or in combination. At least two types of 5-HT receptor appeared to be involved in the response of carotid body chemoreceptors to 5-HT. Transient excitation and chemodepression were mediated via MDL 72222-sensitive (peripheral neuronal) receptors whereas the delayed chemoexcitation and associated hypotension involved a ketanserin-sensitive, presumably 5-HT2-, receptor. It appears unlikely that 5-HT plays a crucial role in chemoreception.

Hypercalcaemic responses to 16,16-dimethyl prostaglandin E2, a stable prostaglandin E2 analogue in chicks.

Intravenous injection of 6.7-60 micrograms of stable prostaglandin E2 analogue, 16,16-dimethyl prostaglandin E2, into 10-day-old chicks caused profound, long-lasting hypercalcaemia. Simultaneous i.v. loading with 50 mumol Ca/bird enhanced the peak response. The responses were accompanied by sedation and lowered skin temperature. Use of acute (simultaneous) 45Ca labelling indicated that the hypercalcaemic responses were due primarily to inhibition of Ca exit from extracellular fluid pools, while chronic (6-day) 45Ca labelling indicated a slower but distinct increase in mobilization of bone Ca pools.

Antimalarial activity of optical isomers of quinacrine dihydrochloride against chloroquine-sensitive and -resistant Plasmodium falciparum in vitro.

Both enantiomers of quinacrine and the racemic form of the drug showed equal activity in vitro against chloroquine-sensitive and -resistant strains of Plasmodium falciparum, without detectable stereoselectivity. This contrasts with observations on chloroquine, where a similar lack of stereoselectivity in vitro is accompanied by a 10-fold loss of activity against the resistant strain. The observed in vivo differences reported for the enantiomers of chloroquine and the observations on the optically active metabolites of chloroquine and quinacrine may therefore be ascribed to a difference in the pharmacokinetics of their enantiomers.

In vitro studies on the mode of action of quassinoids with activity against chloroquine-resistant Plasmodium falciparum.

Using the incorporation of [3H]isoleucine or [3H]hypoxanthine into acid-insoluble products as indices of protein- and nucleic acid-synthetic activity, respectively, it was shown that seven plant-derived quassinoids with differing chemical substitutions all inhibited protein synthesis more rapidly than nucleic acid synthesis in human erythrocytes infected with Plasmodium falciparum, in vitro. Five quassinoids (ailanthinone, bruceantin, bruceine B, glaucarubinone and holacanthone) were effective within 30 min at doses 10 times their 48 hr in vitro IC50 values. Chaparrin and glaucarubol differed in that they did not inhibit protein synthesis during the time course of these experiments when applied at 10 times their in vitro IC50 values. When these compounds were used at 209 and 114 times their respective IC50 values, their observed effects were identical to those of the other quassinoids studied. The time (t50) at which nucleic acid synthesis was reduced to 50% of control was directly proportional to the t50 for protein synthesis, suggesting that failure of nucleic acid synthesis is a consequence of inhibition of protein synthesis. It is concluded that in the malaria parasite, as in eukaryote models, quassinoids are rapid and potent inhibitors of protein synthesis, and that this is most likely due to effects upon the ribosome, rather than upon nucleic acid metabolism.

Comparison of the in vitro activities of quassinoids with activity against Plasmodium falciparum, anisomycin and some other inhibitors of eukaryotic protein synthesis.

Using the inhibition of incorporation of [3H]hypoxanthine as an index of viability of malaria parasites, it was shown that a chloroquine-sensitive strain of Plasmodium falciparum (T9-96) and a chloroquine-resistant strain (K1) did not differ in their sensitivities to the quassinoids ailanthinone, bruceantin and chaparrin. Similarly, there were no differences between the strains in their sensitivities to the protein synthesis inhibitors anisomycin, deacetylanisomycin, cephalotaxine, homoharringtonine, cycloheximide, puromycin and puromycin aminonucleoside. The IC50 values derived for ailanthinone and bruceantin, cycloheximide, homoharringtonine and puromycin were in the nanomolar range, whereas those for the anisomycins, cephalotaxine and the aminonucleoside of puromycin were micromolar or greater. Those drugs tested which contain an ester moiety (ailanthinone, bruceantin, anisomycin, homoharringtonine) were more active than the related drugs (chaparrin, deacetylanisomycin, cephalotaxine) that do not. Cross-resistance to inhibitors of protein synthesis appeared not to accompany resistance to chloroquine.

Terpenoids from Guarea rhophalocarpa.

Four new terpenes including, two sandaracopimaradiene diterpenoids, ent-8(14),15-sandaracopimaradiene-2alpha,18-diol, and ent8(14),15-sandaracopimaradiene-2beta,18-diol, and two lanostane triterpenoids, 23-hydroxy-5alpha-lanosta 7,9(11),24-triene-3-one, and 5alpha-lanosta-7,9(11),24-triene-3alpha,23-diol, were isolated from the methanolic extract prepared from the leaves of G. rhopalocarpa together with the known steroid stigmasterol and the coumarin, scopoletin. The isolates showed weak antiprotozoal activity against Leishmania donovani promastigotes, and Trypanosoma brucei brucei blood stream trypomastigotes, and were devoid of interesting activity towards Plasmodium falciparum. The isolates did not show significant cytotoxic activity against KB cells.

Medicinal plants and the control of protozoal disease, with particular reference to malaria.

Malaria and other protozoal diseases continue to pose serious health problems world-wide. Resistance of the malaria parasites, Plasmodium spp., to drugs such as chloroquine (and, more lately, quinine) occurs with increasing frequency and underlies the necessity to develop new agents for malaria chemotherapy; in the case of diseases caused by species of Leishmania and Trypanosoma there has always been a marked paucity of effective drugs, particularly those with a wide safety margin and minimal or no undesirable side effects. Novel drugs, are required to help alleviate morbidity and mortality and to contribute to the world-wide control of these diseases, in part by helping to reduce the reservoirs of infection. Reliance upon plants for the treatment of disease is high in the developing world and such plants offer a source of new molecules. Research centered upon Plasmodium has produced a number of findings which now prompt the formulation of important questions which may influence and focus the direction of phytotherapy research in the future.

Alstonia species: are they effective in malaria treatment?

A review of the literature on Alstonia species indicates that evidence in support of their effectiveness in the treatment of malaria is controversial. The antiprotozoal activity of the major alkaloid present in Alstonia species, echitamine, was assessed in vitro against Plasmodium falciparum and Giardia intestinalis. Echitamine displayed little antiplasmodial activity, but two quinoline alkaloids from A. coriacea (corialstonine and corialstonidine) were found to have some activity against P. falciparum although this was approximately 10 times less than that of quinine. None of the three Alstonia alkaloids was active against G. intestinalis. These results are discussed in the context of previously published data.

Antimalarial activity from 'Mhekara' (Uapaca nitida Müll-Arg.), a Tanzanian tree.

An aqueous decoction of the root bark of Uapaca nitida Müll-Arg. is currently used locally at the Benedictine Mission at Peramiho in Tanzania to treat malaria. We have now demonstrated that extracts of root bark and leaves of this tree are active against the multidrug-resistant K1 strain of Plasmodium falciparum in vitro. An ethanolic extract of root bark showed activity against P. berghei in mice but at a dose which also showed toxic effects. The use of this plant in treating malaria appears to be novel and further studies would be of value.

Crithidia fasciculata as feeder cells for malaria parasites.

Crithidia fasciculata was used to replace murine peritoneal wash cells as feeder cells for the adaptation of Plasmodium falciparum isolates to continuous culture in vitro, thus avoiding the need to sacrifice animals. Fourteen of 17 malaria parasite isolates in one study, and 12 of 12 isolates in a second study, were successfully adapted to continuous culture in the presence of C. fasciculata, while only 5 of 17 parallel control isolates in the first study, and 2 of 12 isolates in the second study, were adapted in the absence of any feeder cells. Biochemical assays were performed to investigate various hypotheses put forward to explain the mode of action of feeder cells. No effect of C. fasciculata feeder cells was observed on lactate removal, osmotic pressure, or glucose or amino acid content of the malaria culture media. This feeder cell system was shown to reduce the pH of the malaria culture medium. Neither this feeder system nor another system, murine peritoneal macrophages, had any effect on the cysteine content of the culture medium. C. fasciculata was shown to reduce the redox potential of the culture medium, as were other malaria growth enhancers including cysteine and glutathione. This effect on the redox potential of the culture medium is proposed to be a possible mode of action for the feeder cell systems studied.

In vitro and in vivo evaluation of betulinic acid as an antimalarial.

The lupane-type triterpene betulinic acid was isolated from an ethanol extract of the root bark of the Tanzanian tree Uapaca nitida Müll-Arg. (Euphorbiaceae). The in vitro antiplasmodial IC50 values of betulinic acid against chloroquine resistant (K1) and sensitive (T9-96) Plasmodium falciparum were found to be 19.6 micrograms/mL and 25.9 micrograms/mL, respectively. The in vitro activities of several related triterpenes were also evaluated. Betulin was found to be inactive at 500 micrograms/mL for both K1 and T9-96. Ursolic acid exhibited IC50 values of 36.5 micrograms/mL and 28 micrograms/mL, and oleanolic acid exhibited IC50 values of 88.8 micrograms/mL and 70.6 micrograms/mL against K1 and T9-96, respectively. When betulinic acid was tested for in vivo activity in a murine malaria model (P. berghei) the top dosage employed of 250 mg/kg/day was ineffective at reducing parasitaemia and exhibited some toxicity. Betulinic acid has not previously been evaluated for in vivo activity. This is believed to be the first compound to be isolated from U. nitida.

Antiplasmodial activity of extracts and alkaloids of three Alstonia species from Thailand.

Methanol extracts prepared from various parts of Alstonia scholaris, A. macrophylla and A. glaucescens, collected from Thailand, have been assessed for antiplasmodial activity against multidrug-resistant K1 strain of Plasmodium falciparum cultured in human erythrocytes. Pronounced antiplasmodial activity was exhibited by methanol extract of the root bark of A. macrophylla with an IC50 value of 5.7 micrograms/ml. Thirteen indole alkaloids were isolated from the active extract. These alkaloids and a semisynthetic bisindole O-acetylmacralstonine were subsequently tested against the K1 strain of P. falciparum. Pronounced antiplasmodial activity was observed mainly among the bisindole alkaloids, particularly villalstonine and macrocarpamine with IC50 values of 0.27 and 0.36 microM, respectively. The potent alkaloids were further tested against T9-96, the chloroquine-sensitive strain of P. falciparum. It has been found that the active alkaloids, in contrast to chloroquine, have significantly higher affinity to the K1 strain than to the T9-96 strain.