Ecotoxicological classification of the Berlin river system using bioassays in respect to the European Water Framework Directive.

Bioassays as well as biochemical responses (biomarkers) in ecosystems due to environmental stress provide us with signals (environmentally signalling) of potential damage in the environment. If these responses are perceived in this early stage in ecosystems, the eventual damage can be prevented. Once ecosystem damage has occurred, the remedial action processes for recovery could be expensive and pose certain logistical problems. Ideally, "early warning signals" in ecosystems using sensing systems of biochemical responses (biomarkers) would not only tell us the initial levels of damage, but these signals will also provide us with answers by the development of control strategies and precautionary measures in respect to the European Water Framework Directive (WFD). Clear technical guidelines or technical specifications on monitoring are necessary to establish and characterise reference conditions for use in an ecological status classification system for surface water bodies. For the Ecotoxicological Risk Assessment (ERA) of endocrine effects we used an approach of the exposure - dose - response concept. Based on the "Ecototoxicological Classification System of Sediments" that uses pT-values to classify effects in different river systems, we transferred the bio-monitoring data to the five-level ecological system of the WFD. To understand the complexity of the structure of populations and processes behind the health of populations, communities and ecosystems an ERA should establish links between natural factors, chemicals, and biological responses so as to assess causality. So, our ecological monitoring assessment has incorporated exposure & effects data.

Preliminary study of responses in mussel (Mytilus edilus) exposed to bisphenol A, diallyl phthalate and tetrabromodiphenyl ether.

Environmental pollutants with hormonal activity including bisphenol, diallyl phtalate and tetrabromodiphenyl ether, have the potential to alter gonadal development and reproduction in aquatic wildlife. Little is known about the biological impact of environmentally relevant concentrations in mussels. To investigate some aspects of their potential estrogenic action, mussels were continuously exposed during 3 weeks. Gonadal development and vitellogenin like protein levels were examined. Bisphenol (50 microg/l) induced the expression of phospho-proteins in females and spawning in both sexes. Diallyl phthalate and tetrabromodiphenyl ether decreased phospho-protein levels in both sexes and induced spawning in males. Moreover, severe damaging effects on ovarian follicles and ovocytes were observed in both bisphenol A- and tetrabromodiphenyl ether-exposed female mussels.

Effects of selected pharmaceutical products on phagocytic activity in Elliptio complanata mussels.

Municipal wastewaters are recognized as a major source of pharmaceutical and personal care products to the aquatic environment, thereby exposing biota to unknown chronic effects. This study sought to examine the immunotoxic effects of pharmaceutical and urban waste products on the freshwater mussel Elliptio complanata. Hemolymph samples were collected and treated in vitro with increasing concentrations of various drugs (bezafibrate, carbamazepine, fluoxetine, gemfibrozil, morphine, naproxen, novobiocin, oxytetracycline, sulfamethazole, sulfapyridine and trimethoprim) and urban waste related chemicals (coprostanol, caffeine, cotinine) for 24 h at 15 degrees C. In a parallel experiment, mussels were caged and placed in two final aeration lagoons for the treatment of domestic wastewaters. At the end of the exposure period, hemolymphs were tested for phagocytic activity, intracellular esterase activity, cell adherence and lipid peroxidation (LPO). The products that most increased phagocytosis were bezafibrate, gemfibrozil and trimethoprim, while novobiocin and morphine reduced its activity. Intracellular esterase activity was reduced most strongly with sulfamethazole, novobiocin, gemfibrozil, bezafibrate and carbamazepine. Cell adherence was decreased by oxytetracycline, novobiocin and naproxen, and increased by gemfibrozil, bezafibrate and sulfapyridine. Exposure to these products also modulated LPO in hemocytes. Coprostanol and naproxen were more potent to reduce LPO while novobiocin and sulfapyridine were the most potent to induce LPO. The potential to induce LPO was positively correlated with the number of functional groups on the molecule (i.e., its nucleophilicity). Mussels exposed to domestic wastewater treatment plant aeration lagoons had decreased intracellular esterase and phagocytic activity as well, suggesting immunosuppression. PPCPs (pharmaceuticals and personal care products) that are recognized to disrupt cytokine signalling network by the nitric oxide pathway and cell permeability were generally the most potent ones. The data suggest that PPCPs have the potential to cause adverse effects on the immune system of bivalves.

Overview of key phytoplankton toxins and their recent occurrence in the North and Baltic Seas.

The frequency and intensity of harmful algal blooms (HABs) appear to be on the rise globally. There is also evidence of the geographic spreading of toxic strains of these algae. Consequently, methods had to be established and new ones are still needed for the evaluation of possible hazards caused by increased algal toxin production in the marine food chain. Different clinical effects of algae-related poisoning have attracted scientific attention; paralytic shellfish poisoning, diarrhetic shellfish poisoning, and amnesic shellfish poisoning are among the most common. Additionally, cyanobacteria (blue-green algae) in brackish waters often produce neurotoxic and hepatotoxic substances. Bioassays with mice or rats are common methods to determine algal and cyanobacterial toxins. However, biological tests are not really satisfactory because of their low sensitivity. In addition, there is growing public opposition to animal testing. Therefore, there has been increasing effort to determine algal toxins by chemical methods. Plankton samples from different European marine and brackish waters were taken during research cruises and analyzed on board directly. The ship routes covered marine areas in the northwest Atlantic, Orkney Islands, east coast of Scotland, and the North and Baltic seas. The first results on the occurrence and frequency of harmful algal species were obtained in 1997 and 1998. During the 2000 cruise an HPLC/MS coupling was established on board, and algal toxins were measured directly after extraction of the plankton samples. In contrast to earlier cruises, the sampling areas were changed in 2000 to focusing on coastal zones. The occurrence of toxic algae in these areas was compared to toxin formation during HABs in the open sea. It was found that the toxicity of the algal blooms depended on the prevailing local conditions. This observation was also confirmed by monitoring cyanobacterial blooms in the Baltic Sea. Optimal weather conditions, for example, during the summers of 1997 and 2003, favored blooms of cyanobacteria in all regions of the Baltic. The dominant species regarding the HABs in the Baltic was Nodularia spumigena. However, in addition to high concentrations of Nodularia spumigena in coastal zones, other blue-green algae are involved in bloom formation, with changes in plankton communities influencing both toxin profiles and toxicity.

Non-occlusive small bowel necrosis during enteral feeding after pancreaticoduodenectomy.

BACKGROUND: Early enteral tube feeding is widely used after major surgery and trauma. This article is intended to alert surgeons to the possibility of small bowel necrosis following enteral refeeding and to discuss etiology and clinical features. METHODS: A case series from a single surgeon's database at a Tertiary Care Center is reported. Cases were drawnfrom a consecutive series of patients undergoing pylorus-preserving pancreaticoduodenectomy and placement of a needle catheter jejunostomy between January 1998 and June 2004. RESULTS: Two patients receiving early postoperative tube feeding developed sepsis with subsequent small bowel necrosis. Abdominal distension and signs of sepsis developed early postoperatively. Diagnosis was made based on characteristic computed tomography findings. Both patients underwent laparotomy with segmental bowel resection and survived. CONCLUSION: Non-specific septic symptoms associated with recurrent abdominal distension are ominous signs in patients receiving early postoperative enteral tube feeding and should prompt discontinuation of enteral nutrition. Within this scenario, CT imaging represents a valuable adjunct in the early assessment of these patients.

Biochemical and histological responses in mussel (Mytilus edulis) exposed to North Sea oil and to a mixture of North Sea oil and alkylphenols.

Several environmental chemicals are suspected to be responsible for adverse health effects on the reproductive system in various organisms. During this work, environmentally relevant concentrations of North Sea oil were used alone or in combination with alkylphenols and additional PAH to study the effect on vitellogenin-like protein expression and gonadal development in mussels. North Sea oil (0.5 ppm) induced the expression of phospho-proteins in both sexes indicating that some compounds are oestrogen-mimics. This induction was not seen in samples dosed with the mixture but signs of toxic effects were observed in the gonads. Indeed, numerous degenerating ovarian follicles in females and foci, similar to vertebrate melanomacrophage centres, were observed in testes.

Economic evaluation of laparoscopic and open inguinal herniorrhaphies: the effect of cost-containment measures and internal hospital policy decisions on costs and charges.

BACKGROUND: Totally extraperitoneal (TEP) repairs of inguinal hernias, despite having a favorable clinical outcome are often criticized due to higher costs and charges associated with this approach. We, therefore, present a comparison of direct costs and charges between TEP and open tension-free (OPN) repairs, emphasizing the effect of cost-containment measures on the part of surgeons and the hospital's charging (rate-setting) policies on these measurements. METHODS: Itemized direct costs, charges, and reimbursements were determined for 41 TEP and 44 OPN unilateral repairs done between January 1997 and December 1999. Multiple sensitivity analyses were done to evaluate the effect of cost-containment measures and the hospital's rate-setting policies on the differences in costs and charges between the two procedures. The hospital's profits were expressed as profit-cost ratios. RESULTS: The mean direct cost for a TEP repair was $128.58 more than the OPN repair ($795.07[+/-65] vs 666.49 [+/-52]). However, mean charges and hospital reimbursement were $2,139.80 and $1,679.87, respectively, more for the TEP repairs. The profit-cost ratio was significantly higher in the TEP group (2.85:1 vs 1.07:1, P<.001). We found that 79.8% of the difference in direct costs vs 29% of the difference in charges between the two procedures was sensitive to cost-containment measures. Forty-five percent of the difference in charges was due to the hospital's nonuniform rate-setting policies. Long-term follow-up (38 months) showed no recurrence for either procedure. CONCLUSIONS: The direct cost of TEP repairs with the minimal use of disposable instruments in a high-volume center is comparable to the OPN repair. However, due to differences in the hospital's charging policies, TEP repair would appear to be an expensive alternative from the payer's point of view.

A mathematical model for preoperative planning of radiofrequency ablation of hepatic tumors.

BACKGROUND: Radiofrequency ablation (RFA) is rapidly evolving as an effective minimally invasive technique for the treatment of small and unresectable liver tumors. A potential cause of treatment failure is the inability to determine the optimum number of overlapping ablations needed to completely destroy tumors larger than the size of a single ablation. To clarify this relationship, we performed a mathematical evaluation that enables us to accurately estimate the number of ablations needed to completely ablate larger tumors. METHODS: This estimation is based on the assumptions that complete ablation of the surface of a target tumor, including its blood supply, would completely destroy the tumor and that the tumor and ablations produced are perfectly spherical. The smallest possible number of partially overlapping ablations that would completely cover the surface of the target tumor is the same as the number of faces on a regular polyhedron that has a circumscribing diameter equal to or greater than the diameter of the target sphere. RESULTS: This mathematical analysis shows that for a 5-cm ablation device, tumors with diameters ranging between 3.01 and 3.30 cm will require at least four ablations. Tumors between 3.31 and 4.12 cm require six overlapping ablations, and tumors between 4.13 and 6.23 cm require 12 overlapping ablations. The number of ablations needed for larger tumors and for 3-, 4-, 6-, and 7-cm ablation devices are also determined. CONCLUSION: The smallest number of ablations required to completely ablate a spherical target tumor larger than the size of the ablation sphere increases dramatically as tumor size increases. Because this model is geometrically optimized, even a small change in the position of the ablation spheres with respect to the target sphere can leave potentially unablated tumor and thus result in treatment failure.

Transthoracic hepatic radiofrequency ablation.

BACKGROUND: Radiofrequency ablation (RFA) is an alternative for the treatment of unresectable hepatic tumors. Tumors beneath the diaphragmatic dome may be difficult to access by laparoscopy. In these cases, a transthoracic transdiaphragmatic approach for delivering RFA can be used. METHODS: Three patients with hepatic metastatic disease were treated using a transthoracic transdiaphragmatic approach to deliver RFA therapy for tumors in liver segments 7 and 8. The patients underwent thoracoscopy. The tumors were identified using transdiaphragmatic ultrasound, and transthoracic transdiaphragmatic RFA (TTRFA) was performed. RESULTS: In three patients, TTRFA was successfully used to ablate five lesions. There were no perioperative complications, blood loss was minimal,and postoperative hospital stays ranged from 2 to 8 days. There were no recurrences during a follow-up period of 4 to 20 months. CONCLUSIONS: TTRFA is a viable alternative for hepatic tumors located beneath the dome of the diaphragm that are difficult to access by laparoscopy.

Monitoring freshwater sediments.

The objectives of the SENSPOL Expert Meeting on 'Monitoring Freshwater Sediments' held in Antwerp, Belgium, 12-13 September, 2001, were firstly to identify and define problems and secondly to develop a realistic strategy to solve these problems. Both of the stakeholder groups (governmental authorities and the dredging industry) present at the workshop participated in detailed discussions to elucidate the role of sensors in the field of sediments and sediment/water interfaces. The 19 invited experts were agreed that in situ monitoring systems are needed to monitor freshwater sediments. New recognised tools for sediment monitoring would help industry to meet the governmental sediment quality criteria and to handle the data concerning historic river contamination and geological background data. The need to monitor by effect-related studies together with chemical monitoring was stressed. The main focus for development of new sensor tools should be for on site determination of certain priority pollutants where there would be advantage over existing methods or where no suitable method exists, and to monitor biological effects (alarm systems and effect-related on site tests). Sensing technologies would also be useful to monitor bioavailability in sediments in situ to provide information for risk assessment. In addition, they could be of use to monitor bioremediation in situ. A useful role was forseen in dredging sediments, for in situ sediment screening and to guide treatment of dredged material. The new sensing tools presented, included determination of metal concentrations in sediments using the diffuse gradients in thin films (DGT) technique (Lancaster University, UK), an analytical protocol for determination of metal speciation in sediments (Universitat Autonoma de Barcelona, Spain), microbiotests for determination of sediment toxicity (University of Ghent, Belgium), a portable whole cell sensors device for heavy metal bioavailability (VITO, Belgium) and a microfabricated sensor array system for Pb concentration profile measurement in the microM range at the liquid-solid interface (University of Geneva, Switzerland).

Laparoscopic radiofrequency ablation and hepatic artery infusion pump placement in the evolving treatment of colorectal hepatic metastases.

BACKGROUND: Laparoscopic radiofrequency ablation (LRFA) and laparoscopic hepatic artery infusion pump (LHAIP) placement are new treatment options for patients with colorectal liver metastases. This study investigates the selection criteria, safety, efficacy, and preliminary outcomes of patients treated with LRFA and LHAIP placement. METHODS: Fourty five patients with colorectal metastases confined to the liver, 37 of whom had failed systemic chemotherapy, were treated with LRFA and/or LHAIP between September 1996 and December 2001. Treatment selection was individualized, based on each patient's general health, liver function, and tumor size, number, location, and distribution. RESULTS: Twenty patients (44%) had LRFA alone, 10 (22%) had LHAIP placement alone, and 15 (33%) patients had combined LRFA and LHAIP therapy. The LRFA group had a significantly shorter mean operative time and blood loss (p <0.05), but hospital stays were similar when compared to patients receiving LRFA + LHAIP or LHAIP alone. Tumor characteristics were worse in both LHAIP groups, with a higher incidence of tumors >or=4 cm, major vascular involvement, diffuse tumor pattern, bilobar distribution, and involvement of more than three segments. During a mean follow-up period of 11.5 +/- 7.8 months (range, 1-38), the actuarial survival was 70%, 67%, and 50% for LRFA, LRFA + LHAIP, and LHAIP, respectively. LHAIP only patients had the shortest estimated mean survival time of the three groups by Kaplan-Meier survival curves (p = 0.001). CONCLUSION: LRFA and/or LHAIP placement are safe and feasible treatment options for the treatment of colorectal hepatic metastases. The choice of treatment for patients should be based primarily on tumor characteristics. Long-term studies, which will elucidate the role of these evolving treatments, are now under way.

Immunocompetence of bivalve hemocytes as evaluated by a miniaturized phagocytosis assay.

Immune function in bivalves can be adversely affected by long-term exposure to environmental contaminants. Investigating alterations in immunity can therefore yield relevant information about the relationship between exposure to environmental contaminants and susceptibility to infectious diseases. We have developed a rapid, cost-effective, and miniaturized immunocompetence assay to evaluate the phagocytic activity, viability, and concentration of hemocytes in freshwater and marine bivalves. Preliminary experiments were performed to optimize various aspects of the assay including 1) the time required for adherence of hemocytes to polystyrene microplate wells, 2) the time required for internalization of fluorescent bacteria, 3) the ratio of hemocytes to fluorescent bacteria in relation to phagocytosis, 4) hemolymph plasma requirements, and 5) the elimination of fluorescence from (noninternalized) bacteria adhering to the external surface of hemocytes. The results of these experiments showed the optimal adherence time for hemocytes in microplate wells to be 1 h, that phagocytosis required at least 2 h of contact with fluorescently labeled E. coli cells, that the number of fluorescent E. coli cells had a positive effect on phagocytic activity, that at least 2.5 million cells/mL were required to measure a significant intake, and that a linear increase in uptake of bacteria (R = 0.91; p < 0.01) could be obtained with concentrations of up to 1.3 x 10(6) hemocytes/mL. Afterward, the assay was used in two field studies to identify sites having the potential to affect the immunocompetence of bivalves. The first study was conducted on Mya arenaria clams collected at selected contaminated sites in the Saguenay River (Quebec, Canada), and the second examined Elliptio complanata freshwater bivalves that had been exposed to a municipal effluent plume in the St. Lawrence River (Quebec, Canada). In the Saguenay River field study a significant increase in phagocytosis was observed at sites closest to polluted areas. Phagocytotic activity varied over time and was highest during the warmest months (June, July, and August), closely paralleling the spawning period of Mya arenaria clams. In contrast, a drop in phagocytic activity was observed in Elliptio complanata mussels exposed to surface water 4 km downstream of a major municipal effluent plume, with a concomitant increase in the number of hemocytes in the hemolymph. It appears that both immunosuppressive and immunostimulative effects are likely to occur in the field and that responses will be influenced by the type and intensity of contaminants at play.

Molluscan shellfish biomarker study of the Quebec, Canada, Saguenay Fjord with the soft-shell clam, Mya arenaria.

A spatial and temporal survey of six sites in the Saguenay Fjord and of one adjacent site in the St. Lawrence River estuary (Quebec, Canada) was undertaken to study the possible effects of anthropogenic contaminant input on soft-shell clam (Mya arenaria) populations. Bivalve sampling sites were selected because they reflected a range of areas representative of either no known (or apparent) pollution sources or of areas potentially influenced by different gradients and types of contamination sources. The most upstream site selected in the Saguenay Fjord, nearest to a highly populated and industrialized sector, and the most downstream site, near its mouth with the St. Lawrence River estuary, spanned a distance of some 70 km and encompassed the entire intertidal area suitable for Mya arenaria habitat. To measure effects in collected animals, we used a comprehensive battery of biomarkers composed of metallothionein-like proteins (MT), 7-ethoxyresorufin O-deethylase activity (EROD), DNA damage (DD), lipid peroxidation (LPO), vitellinlike proteins (Vn), phagocytosis (PHAG), nonspecific esterase (NspE) activity, and condition factor (weight-to-length ratio of clams). Vn, PHAG, DD, and NspE biomarkers were assayed in hemolymph (or hemocytes), whereas others (MT, EROD, LPO) were determined in the digestive gland. Whole-tissue metal content was also quantified in clams collected in the spatial survey. The spatial survey conducted in June 1997 showed significant effects at all sites, and principal component analysis indicated in addition that the more important responses were linked to the MT, LPO, and NspE biomarkers. Clams collected from sites closest to the upstream reaches of the fjord generally displayed higher levels of tissue metals (cadmium, manganese), as well as greater responses of NspE activity, MT, LPO, and PHAG. Animals collected from sites influenced by municipal wastewaters had higher levels of Vn, suggesting the presence of environmental estrogens. The results of the temporal survey (six monthly samplings of clams at three sites from May through October, 1997) showed that the bivalve reproductive cycle (vitellogenesis and spawning) can modulate the expression of several biomarkers. Vn levels, for example, were positively correlated with DD and EROD and negatively correlated with MT, suggesting that reproduction can influence the susceptibility of clams to some contaminants. Discrimination analysis over the 6 months of sampling revealed that the mean value of the discriminant function changed significantly over time, suggesting important changes in the relative contribution of each biomarker. In short, this study has provided evidence that clam populations in the Saguenay Fjord are impacted by multiple sources of contamination whose effects can be modulated by reproduction.

Laparoscopic antireflux surgery in the elderly.

BACKGROUND: Laparoscopic antireflux surgery is frequently denied to older patients with gastroesophageal reflux disease (GERD) because of a perceived higher operative complication rate, a decreased impact of the intervention on quality of life, and decreased cost effectiveness. This study compares disease severity, surgical outcomes, and impact on quality of life between elderly and young patients with GERD. METHODS: Patients were selected from a prospectively maintained database of 1100 patients who underwent various laparoscopic esophageal procedures at our institution. Only patients having chronic intractable GERD and a minimum 6 months' follow-up were included in the study. Thirty elderly patients with a mean age of 71.2 years (SD +/- 5.6) were compared with a group of 30 younger patients (mean age, 43.9 +/- 12.8 years). Comparisons were made between subjective and objective outcomes, operative results, and health-related quality of life (HQRL) scores using SF-36 instruments. RESULTS: The preoperative symptom assessment scores presenting frequency of symptoms on a 0-4 scale), and preoperative pH and manometry data were comparable in the two groups. Elderly patients had significantly higher ASA (American Society of Anesthesiologists) scores. Each group demonstrated a significant improvement in the postoperative symptom assessment scores and the esophageal functional studies (p<0.05). However, no significant differences were found in terms of postoperative complications, postoperative hospital stay, postoperative symptom scores, Demeester scores, or the HRQL data. CONCLUSION: Laparoscopic antireflux surgery in elderly patients improves acid reflux and appears to be safe and effective as measured by postoperative testing in elderly and young patients.

The cytotoxic and genotoxic potential of surface water and wastewater effluents as determined by bioluminescence, umu-assays and selected biomarkers.

Two bacterial tests employing Photobacterieum phosphoreum (Microtox bioluminescence test) and Salmonella typhimurium TA 1535 pSK1002 (umu-assay) were evaluated to estimate the cytotoxic and genotoxic potential of water samples from the selected rivers in Germany as well as the primary and secondary effluents of some sewage treatment plants. Rainbow trout (Onchorynchus mykiss) were exposed to different concentrations (20-40%) of secondary effluent in the model online aquatic monitoring plant WaBoLu-Aquatox. The toxic potential of water samples from the exposure tanks was determined in two prokaryotic test systems and the biomarkers acethylcholinesterase (AChE) activity in muscle tissue and DNA unwinding assay in liver tissue of fish. Samples from the tested rivers showed no inhibition of the bioluminescence of P. phosphoreum or growth of umu-bacteria. Only primary effluent samples from the treatment plants at the Saale River inhibited the light emission or the growth of test bacteria by more than 20%. The induction ratio of umu-bacteria was in most of the river samples less than the threshold for genotoxicity (IR < 1.5). Only some samples from the Saale River, especially at sites downstream of secondary effluents caused genotoxic responses in the umu-assay. Samples of primary effluents contained the greatest genotoxic potential up to GEUI = 6 which was not detectable in samples of secondary effluents. A concentration range 20-40% secondary effluent inhibited AChE activity in muscle tissue and significantly increased DNA fragmentation in liver tissue of rainbow trout. In contrast, no cytotoxic or genotoxic responses in the umu-assay were caused by water samples. Both bacterial methods can be successfully used to analyse the cytotoxic and genotoxic response of industrial and domestic wastewater and to estimate the effectiveness of sewage treatment units. However, because of their low sensitivity and high susceptibility, they are not reliable as a single test for the detection of cytotoxicity and genotoxicity in surface water. The application of prokaryotic tests systems with biomarkers such as AChE activity and DNA fragmentation in different tissues of test organisms seems to be a useful combination for the assessment of cytotoxic and genotoxic potential in surface water and secondary effluent.

Outcomes of laparoscopic herniorrhaphy without fixation of mesh to the abdominal wall.

BACKGROUND: Recently there has been interest in performing laparoscopic herniorrhaphies without the use of staples or tacks to fix the mesh. Although mesh fixation has been linked to an increased incidence of nerve injury and involves increased operative costs, many surgeons feel that fixation is necessary to reduce the risk of hernia recurrence. This study evaluates the outcomes of laparoscopic herniorrhapies performed with and without mesh fixation at our institution. METHODS: We retrospectively evaluated our last 172 laparoscopic herniorrhaphies, which span a period of conversion from staple fixation to nonfixation of total extraperitoneal herniorrhaphies using systematic chart review and follow-up self-administered questionnaires. The outcomes assessed were the incidences of postoperative neuralgia and hernia recurrence. Adjustment for important prognostic factors was achieved using Cox regression for estimating the risk of recurrence, and multiple logistic regression for estimating the risk of neuropathic complications. RESULTS: Of 172 laparoscopic herniorrhaphies performed in 129 patients since July 1993, 105 were accomplished without mesh fixation, and 67 were performed with fixation of mesh to the abdominal wall. There were no significant differences in demographics between the two groups. A trend toward a higher incidence of neuropathic complications was observed in the mesh-fixation group (risk ratio [RR], 2.2; 95% CI, 0.5-10). A nonsignificant increased risk of hernia recurrence with fixation of mesh was observed (4.2 vs 1.6 per 100 hernia-years at risk; RR, 2.3; 95% CI, 0.4-13.10), but this finding may be associated with a selection bias with regard to giant hernia defects. CONCLUSIONS: Our data suggest that mesh fixation to the abdominal wall may be avoided in total extraperitoneal repairs without increasing the risk of hernia recurrence and neuropathic complications. The increased risk of recurrence observed with mesh fixation possibly results from selection bias. Large randomized controlled studies are needed to determine whether mesh fixation is truly related to neuropathic complications and the incidence of recurrence.

Dedicated minimally invasive surgery suites increase operating room efficiency.

BACKGROUND: The rapid adoption of laparoscopic surgery since the late 1980s added tremendous complexity into the operating room (OR) environment. For each case, a plethora of additional equipment-including monitors, video equipment, wiring, tubing, and cords-had to be set up, prolonging OR turnover time and decreasing OR efficiency. In 1993, the concept of designated minimally invasive surgery (MIS) suites was introduced. MIS suites integrated monitors and video equipment into the OR on ceiling-mounted columns and moved the controls to a centralized nursing station. The overall effect of this innovation on OR efficiency has not been measured. METHODS: Five RNs with varying degrees of MIS experience were instructed on video setup and put-away criteria and then timed while performing a set of standardized tasks. Each set of tasks was performed twice using a standardized surgery model. Differences in setup and put-away times between MIS suites and standard ORs were tested using the t-test for paired comparisons. RESULTS: The mean +/- standard deviation (SD) video setup times were 27.9 +/- 5.3 sec (MIS) and 254.3 +/- 54.0 sec (standard); the put-away times were 19.8 +/- 2.7 sec (MIS) and 222.3 +/- 26.0 sec (standard). The mean difference +/- standard error (SE) in both the setup (226.4 +/- 16.9 sec, p = 0.0001) and put-away times (202.5 +/- 8.6, p = 0.0001) were large and statistically significant. CONCLUSION: Using a simulation model, we have demonstrated that the use of a MIS suite reduces video setup and put-away time significantly, with the potential for significant associated cost savings. This provides just one justification for the high cost of building such "ORs of the future."

Toxicity of domoic acid in the marine mussel Mytilus edulis.

The neurotoxic, immunotoxic and genotoxic effects of domoic acid (DA) on the blue mussel Mytilus edulis were investigated by biomarkers, acethylcholinesterase (ChE) activity in gills, DNA fragmentation in digestive glands, vitality and phagocytosis activity of haemocytes in haemolymph of mussels. After intra muscular injection of DA at the concentrations ranging from 1-500 ng/g body weight (bw), no neurotoxic effect was detected within incubation times of 48 h and 7 d. The vitality of haemocytes remained in all mussels at the level of control samples within 48 h, and increased significantly after 7 d (P<0.05). At DA concentrations ranging from 1 to 100 ng/g bw haemocytes suggested a great phagocytosis activity, but no alteration in their number by both incubation times. By increasing DA concentration of 500 ng/g bw, the number of haemocytes doubled in 48 h without any change in phagocytosis activity. Primary DNA lesions in digestive glands of all injected mussels were determined in acute phase of poisoning within 48 h, and rapidly repaired after 7 d of incubation.

The continuous monitoring of field water samples with a novel multi-channel two-stage mini-bioreactor system.

Toxicity monitoring of field water samples was performed using a novel multi-channel two-stage mini-bioreactor system and genetically engineered bioluminescent bacteria for the continuous monitoring and classification of the toxicity present in the samples. The toxicity of various samples spiked with known endocrine disrupting chemicals and phenol was also investigated for system characterization. The field samples used in this study were obtained from two different sites on a monthly basis--from a drinking water treatment plant, referred to as site N, and from a stream near a dam which is currently being constructed, referred to as site T. These samples were either pumped or injected into the second mini-bioreactors to initiate the toxicity test. Most of the samples did not show any specific toxicity. However, one sample showed to have, based upon the detection results, and was deemed toxic. The samples spiked with phenol showed possible responses in the DPD2540 and TV1061 channels, indicating the occurrence of both membrane and protein damage due to phenol. In the tests using an endocrine disrupting chemical, bisphenol A, DNA damage was detected in the DPD2794 channel with a concentration of 2 ppm. Finally, a simple but novel early warning protocol that can be used in a drinking water reservoir and a suspected place where effluents of toxic materials enter the water sourse was suggested with a schematic diagram. In conclusion, this system showed good feasibility for use as a toxicity monitoring system in the field and as an early warning system, indicating if effluents are toxic.

Incidence of cancer of the pancreas, extrahepatic bile duct and ampulla of Vater in the United States, before and after the introduction of laparoscopic cholecystectomy.

BACKGROUND: Some epidemiologic studies have identified cholecystectomy as a risk factor for pancreatic and biliary cancer. METHODS: We compared the incidence of cancers of the pancreas, extrahepatic bile duct and ampulla of Vater before and after the widespread adoption of laparoscopic cholecystectomy in the United States in 1991, when the use of cholecystectomy increased dramatically. RESULTS: Compared with 1980 to 1991, there was no increase in the incidence of cancer of the pancreas (adjusted incidence rate ratio [IRR] 0.97, 95% confidence interval [CI] 0.94 to 0.99) or extrahepatic bile duct (IRR 0.80, 95% CI 0.74 to 0.87) during 1992 to 1996. There was a small increase in the incidence of ampullary cancer (IRR 1.14, 95% CI 1.03 to 1.26). CONCLUSIONS: We did not find clear evidence of a short-term increase in the incidence of cancers of the pancreas, bile duct, and ampulla of Vater, that was attributable to the increased use of cholecystectomy.