Use of bone meal amendments to immobilise Pb, Zn and Cd in soil: A leaching column study.

The aim of this study is to test the stabilisation of metals in contaminated soils via the formation of low-solubility metal phosphates. Bone apatite, in the form of commercially available bone meal, was tested as a phosphate source on a mine waste contaminated made-ground with high levels of Pb, Zn and Cd. Triplicate leaching columns were set up at bone meal to soil ratios of 1:25 and 1:10, in addition to unamended controls, and were run for 18 months. The columns were irrigated daily with a synthetic rain solution at pH of 2, 3, and 4.4. After 100 days, the leachate Pb, Zn and Cd concentrations of all amended columns were significantly reduced. For 1:10 treatments, release of these metals was suppressed throughout the trial. For 1:25 treatments, Zn and Cd concentrations in the leachates began to increase after 300 days. DTPA and water extractions showed that Pb and Cd were more strongly held in the amended soils. This study concludes that the complexity of soil processes and the small quantities of metals sequestered precluded determination of a metal immobilisation mechanism.

Lack of a relationship between colony-forming efficiency and surviving fraction at 2 Gy.

The relationship between in vitro radiation sensitivity and colony-forming efficiency has been examined for primary human tumors of the cervix, colorectum, and lymph gland. Tumors were cultured using the Courtenay-Mills soft agar clonogenic assay and radiosensitivity was assessed as surviving fraction at 2 Gy. There was no correlation between colony-forming efficiency and surviving fraction at 2 Gy, giving confidence to the use of surviving fraction at 2 Gy as a predictor of clinical outcome.

Primary squamous cell carcinoma of the terminal ileum.

A case of squamous cell carcinoma of the terminal ileum with no underlying duplication or inflammatory disorder is described. The neoplasm seemed to have originated from the surface epithelium, invading the wall and metastasising to the regional lymph nodes. The 65 year old patient was free of disease three years after having had the tumour removed. Previous reports of squamous carcinoma of the small intestine have been associated with intestinal duplication or metastatic disease from distant sites.

Alterations in small-bowel microflora in acute intestinal obstruction.

Small-bowel content was examined bacteriologically whilst fresh and after storage for 24, 48, and 72 h in a modified Stuart's medium. There was little alteration in the viable count of individual intestinal organisms. For accurate quantitative analysis, 0-3 ml of intestinal content was enough. Specimens of small-bowel content were obtained by needle aspiration, and a qualitative and quantitative study was made of the microflora of patients with acute intestinal obstruction and of a control group of patients. Results in the control group confirmed the findings of the results of intubation studies by other workers, that a quantitative gradient of aerobic and anaerobic organisms exists from jejunum to distal ileum. In acute small-bowel obstruction and acute large-bowel obstruction there was a loss of the normal gradient and an increase in the absolute numbers of organisms present; this was particularly marked for anaerobic organisms in large-bowel obstruction.

Management of neutropenic colitis.

Neutropenic colitis is recognized as a rare complication of chemotherapy in haematological malignancies. By contrast, the complication is less well known in relationship to chemotherapy for solid malignancies. There are very few examples reported and this paper adds three further cases and reviews the literature. We emphasize that although some cases of neutropenic colitis may be managed medically, full thickness involvement of the bowel wall may lead to perforation and require surgery. The pathogenesis of this progression is discussed and it is concluded that clinical awareness is important in the diagnosis. The signs of peritonitis or septicaemia are indications for excisional surgery with the formation of a temporary ileostomy.

K-ras gene mutation in colorectal adenomas and carcinomas from familial adenomatous polyposis patients.

Colorectal adenomas and carcinomas from familial adenomatous polyposis (FAP) patients were screened for the presence of K-ras gene mutations at codon 12 using an in vitro amplification step (polymerase chain reaction) followed by dot blot analysis using oligonucleotide probes specific for different mutations at codon 12. We examined 28 colorectal adenomas and two colorectal carcinomas from 12 FAP patients and observed a mutation at codon 12 in seven adenomas and in both carcinomas. The frequency of K-ras gene mutations in colorectal tumours from FAP patients is similar to those in cases of sporadic adenomas and sporadic colorectal carcinomas indicating that the mechanisms involved in their development may be similar.

K-ras gene mutations in adenomas and carcinomas of the colon.

DNA extracted from 29 colorectal carcinomas and 40 sporadic adenomas was amplified by the polymerase chain reaction (PCR) and analysed for the presence of K-ras gene mutations at codon 12 using a panel of synthetic oligonucleotide probes specific for normal and mutated sequences. The presence of mutations was correlated with various histopathological and clinical data. Ten carcinomas (34.5%) and 14 sporadic adenomas (35%) showed K-ras mutations at codon 12. In the carcinoma group, no apparent correlation was found between the presence of mutant oncogenes and the degree of histological differentiation, Dukes' staging or the development of distant metastasis. In the adenoma group, the frequency of mutations increased with the size of the adenoma and the severity of the dysplastic changes. This study confirms that ras gene mutations are common and early events in colon carcinogenesis. They appear to give a selective growth advantage to those polyps with mutations which leads to their increase in size and thus possibly prepare the ground for malignant transformation.

An evaluation of five different methods for estimating proliferation in human colorectal adenocarcinomas.

Five different methods of determining cell proliferation have been compared in samples taken from a group of 125 human colorectal tumours labelled in vivo with iododeoxy-uridine (IUdR). The labelling index (LI) was obtained immunocytochemically using monoclonal antibodies against proliferating cell nuclear antigen (PCNA), the Ki67 antigen and IUdR (IUdRimm). Incorporation of IUdR was also determined flow cytometrically (IUdRfcm) and PCNA expression was measured in both formalin- and methanol-fixed tissue (PCNAf and PCNAm respectively). There was significant variation in the results obtained both within and between the different assays. Paired analysis of the data showed that the correlation between the different methods of determining the LI was poor. However, the IUdRfcm LI was significantly correlated with both IUdRimm (r = 0.39; n = 78; P < 0.001 by Spearman's test) and Ki67 LIs (r = 0.32; n = 87; P < 0.001). The IUdRimm LI was also significantly related to the Ki67 LI (r = 0.44; n = 60; P < 0.001). The median IUdRfcm and IUdRimm LIs were significantly higher in the aneuploid vs. the diploid tumours (17.4% vs. 6.2% for IUdRfcm; 23.2% vs. 18.9 for the IUdRimm; P < 0.001 and P = 0.014 respectively by Mann-Whitney U-test) but none of the other proliferative indices showed this relationship. Finally, none of the LIs showed a significant association with the clinical characteristics of the tumours such as stage, grade, age, sex or fixity. The findings of this investigation highlight the need for carefully controlled studies when assessing the value of proliferation markers in solid human tumours.

Flow cytometric DNA characteristics of radiation colitis--a preliminary study.

The DNA status of 12 rectal biopsies, taken during the investigation of radiation proctitis, was investigated. Of these six were in the acute phase and six in the chronic phase. All of the acute biopsies had diploid DNA, despite bizarre histological epithelial cell appearances. Two of the chronic phase biopsies were to have aneuploid DNA profiles. This finding may be relevant to the increased risk of malignancy in irradiated tissues.

Femoral nerve injury as a complication of pelvic surgery.

Femoral nerve injury is a rare complication of pelvic surgery but may lead to medicolegal actions. The common cause is the use of a long-bladed self-retaining pelvic retractor. The injury is not well recognised in coloproctology practice and this brief article is to draw attention to this complication.

Quantitative magnetic resonance imaging in rectal carcinoma.

T1 and T2 relaxation times have been calculated in 30 patients with rectal carcinoma and seven patients with a fibrotic pelvic mass. The relaxation times were calculated using a multipoint iterative method with data from seven total saturation recovery and six spin-echo sequences. The results show that the calculated T1 relaxation value is a useful discriminant between carcinoma and pelvic fibrosis and should improve the detection of early tumour recurrence.

Gall-stones and oral contraceptives.

PIP: An investigation was undertaken to determine if use of oral contraceptives in premenopausal female patients increased the risk of gallstone formation. Within a 2 year period 100 patients between the ages of 20-45 were divided into 2 groups of 50 each. One group was admitted for cholesterol gallstone surgery while another group was admitted for minor or trauma-related surgery. Women who had ever taken oral contraceptives for 6 month periods prior to hospital admission were kept on record. Results showed that 70% of the 50 patients admitted for gallstone surgery had used oral contraceptives for at least 6 months at one time or another whereas only 14% of the other group of 50 women had done so. This suggests that there is a correlation between the regular use of oral contraceptives and increased risk of gallstone formation. Large doses of estrogens have been shown to change bile flow and composition. These changes may correspond to the increase of gallstones in premenopausal women on oral contraceptives.^ieng

Inguinal hernia: medicolegal implications.

Repair of an inguinal hernia is one of the commonest operations undertaken by surgeons but the role of trauma in causing inguinal hernia is not well understood. This paper does not attempt to discuss the cause of inguinal hernia but seeks to analyse the cases which may be accepted by the Courts as being due to trauma.

Toxic dilatation and perforation in inflammatory bowel disease.

The diagnosis and management of dilatation of the colon and free intestinal perforation in inflammatory or infective bowel disease are reviewed with reference to 32 cases seen during an 8-year period. Toxic dilatation of the colon occurred in 20 patients, including 6 with infective colitis. Ileostomy with subtotal colectomy and mucous fistula is a satisfactory operation for toxic dilatation due to inflammatory bowel disease. Patients with infective colitis can generally be treated without operation. Free intestinal perforation was seen in 12 patients. Colonic perforation may occur in association with toxic dilatation, but more usually it occurs without dilatation as a complication of Crohn's disease. Free perforation of the ileum was seen after a short illness in patients with Crohn's disease.

Massive colonic haemorrhage--the case for right hemicolectomy.

A total of 14 patients had operations for massive colonic haemorrhage. Of the seven who had a right hemicolectomy, four had the bleeding site localised, and three had only 'equivocal' indications of a right-sided source. One of these rebled 11 months later, but all survived and are well. Of the remaining patients, two had left-sided resection, one requiring an immediate second operation for rebleeding, and five, subtotal colectomy, of whom two died. A literature review confirms the suggestion that if the bleeding site has not been identified but, nevertheless, there are clues suggesting it to be right-sided, the best results will be obtained by right hemicolectomy. Left-sided resection should be used only when there is proof of left-sided bleeding, otherwise there will be an unacceptably high mortality. No clues, 'equivocal' indications of a left-sided source, or the presence of bilateral disease, should lead the operator to perform subtotal colectomy.

Is it acute cholecystitis?

In a prospective study of 100 patients presenting with acute right hypochondrial pain and diagnosed clinically by a qualified surgeon as having acute cholecystitis, we have shown that the diagnostic error can be considerable. Twenty-five of these patients were found to have a different diagnosis on subsequent investigation and in a further 11 patients, no definite diagnosis could be established. This emphasises the need for careful investigation of patients with this presenting complaint.

Ischaemic dilatation of the colon.

The present paper describes the presentation and management of 9 patients who developed dilatation in the colon during the course of spontaneous ischaemic colitis. The length of history varied from 16 hours to 6 weeks. The patients usually had diarrhoea and abdominal pain but no bleeding and posed a difficult diagnostic problem. At laparotomy, three distinct types of colonic dilatation were recognised. Dilatation of non-diseased colon proximal to localised ischaemic segments occurred in 2 patients, 3 patients exhibited dilatation of obviously gangrenous colon, 4 patients showed dilatation of ischaemic but possibly viable colon, yet in 1 of these, multiple sealed perforations were present. Resection of the obvious or possibly gangrenous colon was the treatment used but in the 2 patients with dilatation due to stricture, transverse colostomy alone was employed.

Indications for and results of operation in inflammatory bowel disease.

Of 363 patients with inflammatory bowel disease presenting between 1972 and 1983, 166 required definitive operation. A classification by histological type distinguishes Crohn's disease (CD) from ulcerative colitis (UC) and indeterminate inflammatory bowel disease. CD is divided into predominantly ileal disease (81), total or subtotal colonic disease (74) and distal disease (22), whilst UC is classified into colonic (95) or distal disease (63). Most patients with ileal disease required operation for chronic persistent symptoms. In patients with total colonic involvement a greater proportion of patients with CD than those with UC came to surgery. Very few patients with distal disease required surgery. After resection for ileal disease there was a low incidence of anastomotic leakage (3%) and no operative mortality. There was an overall operative mortality of 8% after colonic resection. This was much lower in the non-urgent cases but rose to 12% in urgent cases.

Management of perianal Crohn's disease.

Symptomatic anal disease (excluding skin tags) was observed in 49 out of 151 successive patients treated for Crohn's disease. Two main types of anal disease were encountered: anal ulceration (23 patients) and anal abscesses and fistulae (26 patients). The ulcer group rarely required local surgical treatment. In the fistula group, a low tract was demonstrated and laid open in 20 patients. The healing times after operation in these patients were compared with those of 18 patients with non-Crohn's fistula-in-ano treated by the same method. No significant difference between the two groups could be demonstrated. Surgical treatment of low fistula-in-ano may be undertaken in patients with Crohn's disease, provided the bowel disease is under adequate control.

Diagnosis and management of psoas abscess in Crohn's disease.

Four patients with Crohn's disease complicated by psoas abscess are described. These patients did not have general or abdominal signs of sepsis but they all showed wasting of the right quadriceps femoris and hip flexion. It is important to examine the hip and thigh in patients with known Crohn's disease who are on medical treatment. Surgical treatment of a Crohn's psoas abscess should include resection of recurrent disease, fashioning of the anastomosis remote from the abscess cavity, and long-term (21 days) drainage of the abscess cavity to avoid the possibilities of faecal fistula or recurrent abscess.