Severe gestational gigantomastia: management challenges

Gestational gigantomastia is rare and characterised by rapid and disproportionate enlargement of the breast during pregnancy. It often requires surgical removal of more than 1500 g of breast tissue. Of the 50 case reports published worldwide, not one was in South African literature. This unusual case report is of a female presenting with gigantomastia at five weeks gestational age. The patient was multiparous and decided to terminate the pregnancy due to the physical and emotional effects of the large, pendulous breasts. Management included breast reduction and free nipple grafting in a staged approach. The complications are briefly outlined. Despite rare presentation, patient satisfaction was achieved.

Severe gestational gigantomastia: management challenges

SUMMARY Gestational gigantomastia is rare and characterised by rapid and disproportionate enlargement of the breast during pregnancy. It often requires surgical removal of more than 1500 g of breast tissue. Of the 50 case reports published worldwide, not one was in South African literature. This unusual case report is of a female presenting with gigantomastia at five weeks gestational age. The patient was multiparous and decided to terminate the pregnancy due to the physical and emotional effects of the large, pendulous breasts. Management included breast reduction and free nipple grafting in a staged approach. The complications are briefly outlined. Despite rare presentation, patient satisfaction was achieved. Keywords: severe gestational gigantomastia, disproportionate enlargement, breast, pregnancy, mastectomy

Evaluating the effect of seasonal temperature changes on the efficiency of a rhizofiltration system in nitrogen removal from urban runoff

The study presents an evaluation of nitrogen removal efficiency of a pilot-scale rhizofiltration system in Pretoria, South Africa. The rhizofiltration system was divided into two sections, one side planted with common reeds (Phragmites australis) and the other side was without plants kept as a control. The objective of the study was to evaluate the influence of seasonal temperature on the removal of nitrogen species from the simulated urban runoff using the rhizofiltration system. The final effluent from the filter was collected bimonthly at different sampling points for 10 months after an application time of 5 min and 25 min. Duplicate samples were taken to determine the concentrations of TKN (Total Kjeldahl nitrogen), ammonium, nitrate and chemical oxygen demand (COD) for the raw influent and final effluent from the rhizofiltration system. Temperature and pH were determined on-site. During the monitoring period, there was no significant difference in the inflow concentration of ammonium in colder and warmer months for both planted and control sides. Furthermore, the composition of the feed medium to the rhizofilter was kept the same in both cold and warm season and for both planted and control sides. The removal of ammonium in colder and warmer months was not significant in both systems. At an average temperature increase of 5.2 °C in the warmer months, the ammonium removal efficiency in the planted side increased by 7.5%, while for the control side the removal efficiency increased by 2.4%. The difference in removal was not significant between the averages of effluent ammonium after an application time of 25 min in colder versus warmer months for the planted and control sides of the system. Furthermore, an increased nitrification rate was more evident in the planted than in the control side, which was subsequently denitrified. It was observed that 60.4% of nitrate concentration was potentially removed in the planted side whereas 45.4% was potentially denitrified in the control side. These results suggest positive correlation between nitrate concentration and the potential for denitrification. The nitrate removal efficiency dropped to 32.2% for the planted site and to 26.1% for the control system in colder months. Temperature had an effect on nitrogen removal, since nitrogen removal efficiency decreased in colder months. Complete nitrogen removal could not be achieved under the operating conditions.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Beyond Belsey: complex laparoscopic hiatus and diaphragmatic hernia repair

BACKGROUND

Diaphragmatic and hiatus hernias can cause mild chronic symptoms or have an acute presentation with gastric volvulus and obstruction. Elective or emergency surgery is indicated in symptomatic patients and nowadays is generally performed laparoscopically.

METHODS

We report four different types of hernias: a giant hiatus hernia following a gastric pull-up for recurrent congenital diaphragmatic hernia; a Bochdalek hernia in a pregnant young woman; concomitant hiatus and Morgagni hernias; and a giant hiatus hernia occupying the right chest. All were approached laparoscopically, either electively or as an emergency.

RESULTS

Surgery led to a resolution of symptoms in all the cases. We had no any intraoperative complications. Two patients developed minor postoperative complications (chest infection). No recurrences were found during a mean follow-up of 18 months.

CONCLUSIONS

Transabdominal laparoscopic approach is a safe and feasible approach to all cases of symptomatic hiatus and diaphragmatic hernia.

Late life revision surgery for dilated colonic conduit in long gap oesophageal atresia

Long gap oesophageal atresia presents a surgical challenge as there is insufficient length of the oesophagus to restore continuity. Oesophageal replacement is generally achieved using a conduit, taken from the stomach, jejunum or colon. Preferences of approach vary between and within surgical centres. Specific to colonic interposition, the continued growth and dilation of the interposed segment may lead to redundancy. Revision surgery in these cases is challenging and has been sparsely described in adult patients. We present two patients who had colonic interposition for long gap oesophageal atresia in infancy and who then underwent successful revision surgery in their fifth decade.

Laminin, laminin-entactin and extracellular matrix are equally appropriate adhesive substrates for isolated adult rat cardiomyocyte culture and experimentation

Although techniques for isolating and culturing adult cardiomyocytes were developed four decades ago, it still remains a challenge to isolate high yields of healthy viable cardiomyocytes, to maintain them in culture, and to use them successfully in experiments. This is due to the difficulty in deciding which adhesive substrate and buffer composition to use. Therefore this study aimed to (1) identify a robust experimental buffer to sustain survival of cultured adult rat cardiomyocytes (ARCMs) during control normoxic conditions, and (2) to identify an adhesive substrate that provides optimal cell adherence, not only during normoxia, but especially during simulated ischemia-reperfusion (SIR) experiments. Adhesion and viability of ARCMs were evaluated on laminin, laminin-entactin (LE), and extracellular matrix (ECM) at concentrations between 25-200 ug/ml, in three different normoxic experimental buffers and under SIR conditions. Differences in normoxic buffer composition had no effect on the adherence of ARCMs, but had a significant effect on mitochondrial function and thus cell viability. HEPES buffered PBS supplemented with 10 mM glucose was not sufficient to sustain cell viability unless 2 mM pyruvate was added, yet a cocktail of PBS and M199 provided an even greater viability. Finally, laminin, LE, and ECM retained similar numbers of ARCMs per concentration, but only provided efficient adhesion at concentrations ≥ 100 ug/ml.

Illegible handwriting and other prescription errors on prescriptions at National District Hospital, Bloemfontein

Background: It is generally accepted that doctors have illegible handwriting. The writer usually knows what is written, but other parties often have problems with reading and interpreting. Aim: The aim of the study was to determine whether illegible doctors’ handwriting and other factors that can lead to dispensing errors occur on prescriptions at National District Hospital. Method: In part one the prescriptions of 20 doctors were read by five doctors, nurses and pharmacists to detect who could read it most accurately. In part two, these doctors were asked to write a prescription with an IntelliPen®. Results: From the 300 measurements, 88% of the doctors read the prescriptions correctly, compared with 82% of the nurses and 75% of the pharmacists. A potential fatal error was lorazepam injection 4 mg, which was read as 40 mg (lethal dose) by 20% of healthcare workers (HCWs). With the IntelliPen® only 39% of the prescriptions were readable. Only 65% of prescribers could be identified from their handwriting or the name stamp used. Conclusion: Pharmacists read the prescriptions worst and they are the people who must dispense the prescriptions. Some of the reading mistakes were critical and could be lethal. Many of the prescriptions did not meet the legal requirement for prescriptions. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: 10.1080/20786190.2016.1254932

Intraoperative distensibility measurement during laparoscopic Heller's myotomy for achalasia may reduce the myotomy length without compromising patient outcome

Our study aimed to assess whether intraoperative esophagogastric junction (EGJ) distensibility measurement using the EndoFLIP EF325 catheter (Crospon Ltd., Galway, Ireland) could potentially be used to guide laparoscopic Heller's myotomy (LHM), potentially modifying the operation outcome and comparing this clinically to our previous technique of gastroscopic assessment. Following a full diagnostic assessment with manometry and endoscopy patients with achalasia were divided into two groups. A retrospective cohort of patients operated on between 2007 and 2010 had a gastroscopy-guided LHM (G-LHM) with a standardized myotomy of 8 cm on the esophagus and 3 cm on the stomach. From 2010, patients were prospectively studied with an EndoFLIP-guided LHM (E-LHM). The length of the myotomy was dictated by intraoperative distensibility monitoring of the EGJ. All patients with achalasia recorded Urbach quality of life scoring preoperatively and 6 months postoperatively. A further group of normal laparoscopic control patients (E-LC) without any esophageal pathology also underwent intraoperative EGJ distensibility monitoring. Thirty-eight patients took part, 15 in the E-LC group, 8 in G-LHM group and 15 in the E-LHM group. We revealed that patients with achalasia in the E-LHM group had a significantly smaller EGJ cross-sectional area and distensibility than the E-LC group. Myotomy and fundoplication increased the distensibility of the EGJ to a value greater than normal control patients. Patients in the G-LHM group had a standard myotomy of 11 cm; patients in the E-LHM group had a variable length myotomy of 6 cm (IQR 5.0-6.0). In both G-LHM and E-LHM groups, there was a significant improvement in patient's quality of life with no significant difference between the groups. Our study has shown that the EndoFLIP system was effective at measuring distensibility changes during LHM. LHM significantly increases the distensibility of the EGJ and also significantly improves patient symptoms. E-LHM may reduce the overall myotomy length, and this does not appear to compromise the clinical outcome.

Yeasts Associated with Culex pipiens and Culex theileri Mosquito Larvae and the Effect of Selected Yeast Strains on the Ontogeny of Culex pipiens

The success of mosquitoes in nature has been linked to their microbiota and bacteria in particular. Yet, knowledge on their symbioses with yeasts is lacking. To explore possible associations, culturable yeasts were isolated from wild larvae of Culex pipiens and Culex theileri. These yeasts were classified using restriction fragment length polymorphism (RFLP) analyses and identified by sequencing the D1/D2 region of the 26S rRNA gene. Representative strains of Candida, Cryptococcus, Galactomyces, Hannaella, Meyerozyma, Pichia, Rhodosporidium, Rhodotorula, Trichosporon and Wickerhamomyces were isolated. Our results provide, to our knowledge, the first records of the yeast microbiota from wild mosquito larvae and show that they may harbour potential clinically relevant yeast species, including the well-known opportunistic human pathogen Candida albicans. Also, diminished numbers of yeast isolates originating from adults, compared to larvae, support the hypothesis of microbial reduction/elimination during adult emergence and extend it to include yeasts. In addition, strains of Candida albicans, Candida glabrata, Candida pseudolambica, Cryptococcus gattii, Metschnikowia bicuspidata, Saccharomyces cerevisiae and Wickerhamomyces anomalus were tested as sole feed during a 21-day feeding experiment wherein cumulative larval growth, survival and pupation of Cx. pipiens were recorded. Although most yeasts supported larval growth in a similar manner to the positive control S. cerevisiae strain, the different yeast strains impacted differently on Culex pipiens ontogeny. Notably, survival and pupation of larvae were negatively impacted by a representative strain of the primary pathogen C. gattii - signifying some yeasts to be natural antagonists of mosquitoes.

Ivor-Lewis oesophagogastrectomy with Roux-en-Y duodenal bypass

Oesophagectomies and gastrectomies are performed predominantly for the treatment of malignant disease. However, in this case series, we describe three patients with benign disease who had a laparoscopic oesophagogastrectomy with gastroduodenal detachment and Roux-en-Y biliary diversion, and discuss the operative feasibility and consequent patient outcomes. Our aim was to modify the procedure using an established reconstruction already practised in gastric and bariatric surgery, thereby preventing operative sequelae that lead to a poor quality of life (eg reflux oesophagitis and vomiting). During the first postoperative year, our first two patients experienced weight loss, indigestion and lower bowel symptoms with no apparent improvement in gastric function compared with a standard gastric tube pull-up reconstruction. In the longer term, in both patients, the gastric tube interpositions appeared to function well and there was no evidence of gastro-oesophageal reflux disease, delayed gastric emptying or troublesome indigestion. Our third patient, who had lifelong severe reflux symptoms, was eating normally three months after the operation with no need for antacid medication. We therefore conclude that laparoscopic Ivor-Lewis oesophagogastrectomy with Roux-en-Y bypass is a more complex reconstruction with added risks but may in the long term result in better overall outcomes and satisfaction for patients, particularly those with benign disease.

Vitamin K and other markers of micronutrient status in morbidly obese patients before bariatric surgery

BACKGROUND

Micronutrient deficiencies occur in morbidly obese patients. The aim of this study was to assess vitamin deficiencies prior to bariatric surgery including vitamin K about which there is little data in this population.

METHODS

A prospective assessment of 118 consecutive patients was performed. Clinical allied with haematological and biochemical variables were measured. Micronutrients measured included vitamins K1 , PIVKA-II (protein-induced in vitamin K absence factor II), vitamin D, vitamin B12 (holotranscobalamin), iron, transferrin and folate.

RESULTS

Patients were aged 49 ± 11 [mean (SD, standard deviation)] years, body mass index (BMI) 50 ± 8 kg/m(2), 66% female and 78% Caucasian. Hypertension was present in 47% and type 2 diabetes in 32%. Vitamin D supplements had been prescribed in 8%. Micronutrient insufficiencies were found for vitamin K (40%), vitamin D (92%) and vitamin B12 (25%), and also iron (44%) and folate (18%). Normocalcaemic vitamin D insufficiency with secondary hyperparathyroidism was present in 18%. Iron and transferrin levels were associated with age, sex and estimated glomerular filtration rate. Vitamin K levels were associated with age, and inversely with BMI and diabetes mellitus; and PIVKA-II with smoking, triglycerides and liver function markers. Vitamin D levels were associated with statin use and prescription of supplements and inversely with BMI. Vitamin B12 levels were associated with ethnicity and HbA1c.

CONCLUSION

Micronutrient status shows differing relationships with age, gender and BMI. Vitamin K insufficiency was present in 40% and not related to deficiencies in other vitamins or micronutrients. Vitamin D and vitamin K supplementation should be considered prebariatric surgery in patients with diabetes or severe insulin resistance.

Involvement in and Views on Social Responsibility of Gauteng Members of the South African Society of Physiotherapy: A Cross-sectional Survey

How do physiotherapists in Gauteng Province,who are members of the South African Society of Physiotherapy(SASP), view social responsibility?A cross-sectional survey was conducted after ethics approval.All 1 098 Gauteng members of the SASP were invited via a thirdpartye-mail to reach the a priori minimum sample size of 97. Theweb-based questionnaire was developed from literature, an earlierSASP survey and a position paper of the American Physical TherapyAssociation (APTA). Five experts validated the instrument.The Likert scale scores indicating agreement with indicatorsof social responsibility were totalled to form a composite socialresponsibility score. The chi-square test for independence was used to determine associations between the categorisedcomposite social responsibility score and categorical variables. Mean difference of continuous variables betweenthe categorised core for two groups were tested using the two-sample t-test. All variables with a P-value less than0.05 were included in the logistic regression analysis to investigate predictors of the necessity of social responsibility.The survey was completed by 163 participants. Of the sample, 96.9% viewed social responsibility as important.Subjects agreed most with “advocating for the health needs of society” (74,2%) and the least with “political activism”(6.1%). Compulsory community service positively influenced 74.6%.Most physiotherapists in the study viewed social responsibility as important and were involved in volunteering.There is scope to broaden the understanding among physiotherapists of what social responsibility entails.

Massive spontaneous diaphragmatic rupture in Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) is a rare disorder caused by abnormalities in the synthesis and structure of collagen. The resultant tissue fragility and weakness can lead to multiple surgical conditions. In this report we present the very rare and life threatening case of a massive spontaneous diaphragmatic rupture in a 35-year-old man with EDS and reflect on the literature, highlighting points to consider when managing such complex patients.

Population-based study of the need for cholecystectomy after obesity surgery

Background

Weight loss following obesity surgery is associated with gallstone formation, but there is limited evidence on whether prophylactic cholecystectomy is indicated during obesity surgery. The aim of this study was to clarify the need for cholecystectomy following obesity surgery.

Methods

A Swedish nationwide, population-based cohort study was conducted during the 22-year interval 1987–2008. Need for later cholecystectomy for gallstone disease was assessed in patients who had undergone obesity surgery in comparison with the general population of corresponding age, sex and calendar year. This need was also compared with the need for cholecystectomy in cohorts of patients who had undergone antireflux surgery and appendicectomy. Standardized incidence ratios (SIRs) with 95 per cent confidence intervals (c.i.) were calculated to estimate the relative risk.

Results

In the obesity surgery cohort of 13 443 patients, the observed number of cholecystectomies (1149, 8·5 per cent) exceeded the expected number by over fivefold (SIR 5·5, 95 per cent c.i. 5·1 to 5·8). The observed need for imperative cholecystectomy (for cholecystitis, cholangitis, pancreatitis, or jaundice; 427, 3·2 per cent) was also greater than expected (SIR 5·2, 4·7 to 5·7). The SIR peaked 7–24 months after obesity surgery and decreased with longer follow-up. The SIRs for cholecystectomy after antireflux surgery and appendicectomy were 2·4 (2·2 to 2·6) and 1·7 (1·6 to 1·7) respectively.

Conclusion

An increased need for cholecystectomy after obesity surgery was confirmed, but was probably partly due to an increased detection of gallbladder disease only because of the surgery; the individual's risk of imperative cholecystectomy was low. Therefore, prophylactic cholecystectomy might not be recommended during obesity surgery.

Intraductal papillary mucinous neoplasm of the oesophagus: an unusual case of dysphagia

We report the case of a 58-year-old woman presenting with dysphagia secondary to an intraductal papillary mucinous neoplasm arising from a heterotopic pancreas in the oesophageal wall. This was successfully treated with a laparoscopic/thoracoscopic ivor Lewis oesophagectomy. Dysphagia is the most common symptom of oesophageal tumours regardless of aetiology of the tumour and can be treated successfully with surgical resection. Through an extensive search of the literature, we found that a heterotopic pancreas in the oesophagus is extremely rare with only ten cases being reported. We describe what we believe to be the first case of a heterotopic pancreas in the oesophagus transforming into an intraductal papillary mucinous neoplasm.

Circumferential resection margin (CRM) in esophageal (OC) and gastroesophageal (GOJ) cancers

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Background: We hypothesized that CRM size affect survival and local recurrence for OC and GOJ cancer. We also assessed the utility of CT in predicting margin status.

Methods: A retrospective analysis of a prospective database was carried out on all patients who had esophagectomy between January 2000 and July 2008. Patients diagnosed with OC and GOJ tumors on final pathologic examination were included. Distance from the CRM was assessed by a specialist upper GI pathologist. Two radiologists, blinded to postoperative margin status, reviewed preoperative CT scans using 16 separate parameters, comparing them to measured CRM status.

Results: 419 patients were assessed. 223 pts had OC or GOJ type 1 tumors, average age 62 years (range 36–80), mean follow-up 5.8 years (2-9.5). There were 125 deaths and median overall survival (OS) 3.33 years (95% CI 2.76-6.24). 76 patients had recurrence at a median of 1.3 years (0.1-4.7). For 144 patients had OC or GOJ type 1 T3 tumors. Selected results are presented in the Table. There was no CRM size above which there was no further reduction in recurrence. Postoperative chemoradiation did not improve OS (p=0.79) or recurrence (p=0.96) in patients with CRM of 0-1 mm. In 50 patients the CT parameters significantly correlated with margin status were largest axial diameter (p=0.003) and contact with adjacent structures (p=0.005). A complete statistical review with multivariate and subgroup analyses will be presented.

Conclusions: CRM size is strongly correlated with survival and recurrence in OC and type 1 GOJ tumors. Prediction of a close CRM could be used to select for more intensive therapy prior to undergoing radical surgery, such as chemoradiation. Preoperative CT can help in this prediction.

[Table: see text]

No significant financial relationships to disclose.

Effects of small increases in copper levels on culturable basidiomycetous yeasts in low-nutrient soils

AIMS

Investigating the effect of perturbations, with relatively low Cu concentrations, on yeast community composition in low-nutrient virgin soil.

METHODS AND RESULTS

Culturable soil yeast populations were monitored at an experimental site treated with the fungicide copper oxychloride (10 mg Cu per kg soil). Yeast numbers were unaffected by additional Cu; however, a shift in yeast community composition from Hymenomycetes to Urediniomycetes species occurred. Subsequent growth experiments conducted with a synthetic liquid medium revealed that hymenomycetous and urediniomycetous yeasts were affected differently by 1 and 10 mg l(-1) Cu. Soil microcosm experiments then indicated that additional 10 mg kg(-1) Cu may improve the competitive ability of urediniomycetous yeasts in the presence of hymenomycetous yeasts.

CONCLUSIONS

The shift from hymenomycetous to urediniomycetous yeasts, as a result of slightly increased soil Cu levels, may be because of hymenomycetous yeasts being more sensitive to elevated Cu levels and urediniomycetous yeasts having an improved competitive ability in the presence of elevated Cu levels.

SIGNIFICANCE AND IMPACT OF THE STUDY

Yeast community composition of pristine low-nutrient soils may change as a result of perturbations with relatively low concentrations of Cu. Urediniomycetous yeasts should be studied as potential bio-indicators of Cu perturbations.

Acute superior vena cava obstruction following Ivor-Lewis oesophagectomy

A 53 year old man developed upper body swelling, hypotension, anuria and a metabolic acidosis within 24 h following an Ivor-Lewis oesophagectomy. His co-morbidities included hypertension, hypercholesterolaemia, ischaemic heart disease and he was a smoker. He did not have radiotherapy but had received neo-adjuvant chemotherapy through an in-dwelling right subclavian central venous catheter. Azygous vein ligation during oesophagectomy resulted in acute upper body venous hypertension and signs of hypovolaemic shock which were attributed to undiagnosed thrombotic occlusion of the superior vena cava. The patient was anticoagulated and made a full recovery after a period of stay in intensive care.

Degradation of aflatoxin B(1) by fungal laccase enzymes

The enzymatic degradation of aflatoxin B(1) (AFB(1)) by white rot fungi through laccase production was investigated in different liquid media. A significant (P<0.0001) correlation was observed between laccase activity and AFB(1) degradation exhibited by representatives of Peniophora and Pleurotus ostreatus cultivated in minimal salts (MSM) (r=0.93) and mineral salts - malt extract (MSB-MEB) (r=0.77) liquid media. Peniophora sp. SCC0152 cultured in MSB-MEB liquid medium supplemented with veratryl alcohol and sugarcane bagasse showed high laccase activity (496U/L), as well as 40.45% AFB(1) degradation as monitored using high performance liquid chromatography. P.ostreatus St2-3 cultivated in MSM liquid medium supplemented with veratryl alcohol resulted in laccase activity of 416.39U/L and 35.90% degradation of AFB(1). Aflatoxin B(1) was significantly (P<0.0001) degraded when treated with pure laccase enzyme from Trametes versicolor (1U/ml, 87.34%) and recombinant laccase produced by Aspergillus niger D15-Lcc2#3 (118U/L, 55%). Aflatoxin B(1) degradation by laccase enzyme from T. versicolor and recombinant laccase enzyme produced by A. niger D15-Lcc2#3 coincided with significant (P<0.001) loss of mutagenicity of AFB(1), as evaluated in the Salmonella typhimurium mutagenicity assay. The degradation of AFB(1) by white rot fungi could be an important bio-control measure to reduce the level of this mycotoxin in food commodities.

Growth and mating of Cryptococcus neoformans var. grubii on woody debris

A total of 36 Cryptococcus neoformans strains originating from South Africa were screened for wood degrading enzymes. All strains tested positive for cellulase activity while none where capable of xylan degradation. Three C. neoformans var. grubii strains, originating from clinical and environmental samples, representing the same genotype (VNI/AFLP1-C. neoformans var. grubii) and MATalpha, were evaluated for growth on debris of two common tree species in South Africa: Acacia mearnsii and Eucalyptus camaldulensis. The mating capability of all the C. neoformans strains was evaluated on similar debris. Strains grown on A. mearnsii yielded substantially greater yeast populations. A total of 26%, 6%, 46%, and 80% of the 36 C. neoformans strains tested were either able to mate or develop filaments when crossed on A. mearnsii and E. camaldulensis debris, V8 juice, and yeast carbon base (YCB) agar, respectively. Filamentation and monokaryotic fruiting was observed in 3% of strains when C. neoformans was cultured on either A. mearnsii, E. camaldulensis debris, or YCB. The results indicate that this fungus is capable of completing its life cycle and can produce basidiospores on woody debris. In the future, these findings should be considered when studying the epidemiology, microbial ecology, and proposed infection process of this global pathogen.

Analysis of trace amounts of carbon dioxide, oxygen and carbon monoxide in nitrogen using dual capillary columns and a pulsed discharge helium ionisation detector

Gas mixtures of trace amounts of carbon dioxide (CO(2)), dioxygen (O(2)), and carbon monoxide (CO) in dinitrogen (N(2)) were separated and quantified using parallel dual capillary columns and pulsed discharge helium ionisation detection (PDHID). The detection limits (9 x 10(-9) mol mol(-1) for CO(2), 7 x 10(-9) mol mol(-1) for O(2) and 37 x 10(-9) mol mol(-1) for CO) were lower than those reported previously for similar methods. Uncertainties were calculated and results were validated by comparison of the CO and CO(2) results with those obtained using conventional methods. The method was also used to analyse nitrogen, carbon dioxide and carbon monoxide in oxygen.

Shangaan patients and traditional healers management strategies of hypertension in Limpopo Province

The study explored the cultural care beliefs, values and attitudes of Shangaans patients’ and traditional healers’ management strategies of hypertension in the Limpopo Province. The study aimed to describe the cultural values, beliefs and practices including taboos, rituals and religion within the world-view of the Shangaans. The study was undertaken in the Mopani region of the Greater Giyani area, with the purpose of recommending improvements to patient care in this area.

Shangaan patients and traditional healers management strategies of hypertension in Limpopo Province

The study explored the cultural care beliefs, values and attitudes of Shangaans patients’ and traditional healers’ management strategies of hypertension in the Limpopo Province. The study aimed to describe the cultural values, beliefs and practices including taboos, rituals and religion within the world-view of the Shangaans. The study was undertaken in the Mopani region of the Greater Giyani area, with the purpose of recommending improvements to patient care in this area.

Comparative analysis of environmental DNA extraction and purification methods from different humic acid-rich soils

AIM

To establish a rapid, improved soil environmental DNA extraction and purification protocol.

METHODS AND RESULTS

Three different soil DNA isolation and four purification strategies were compared on different soil samples with variable rates of success. Bead beating extraction gave significantly higher DNA yields than microwave-based and liquid nitrogen grinding DNA extraction methods. The inclusion of soil washing prior to cell lysis decreased the amount of purification steps required. Although these soil types differed, polyvinylpolypyrrolidone (PVPP)-sepharose 2B column elution was sufficient for all three samples, yielding DNA pure enough for successful application in molecular studies. One soil sample retained 80% of the initial DNA after successful purification.

CONCLUSIONS

Optimization of a purification protocol confirmed that only a combination of previously described methods proved sufficient in yielding pure environmental DNA from humic-rich soils. Total processing time for DNA extraction and subsequent purification from multiple samples was considerably more rapid than the previously described methods.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study developed a new optimized soil DNA extraction and purification protocol that is suitable for different environmental sources that are rich in humic acid content.

Shangaan patients and traditional healers management strategies of hypertension in Limpopo Province

The study explored the cultural care beliefs, values and attitudes of Shangaans patients' and traditional healers' management strategies of hypertension in the Limpopo Province. The study aimed to describe the cultural values, beliefs and practices including taboos, rituals and religion within the world-view of the Shangaans. The study was undertaken in the Mopani region of the Greater Giyani area, with the purpose of recommending improvements to patient care in this area. Data collection was done by conducting focus groups and individual interviews. The following themes emerged: Hypertension, The traditional healer: the instrumental role, Traditional medicine versus Western medicine, Magico-religious healings, Cultural beliefs of Shangaans and hypertension, Experiences of hypertensive patients with regard to traditional healers and hypertension.

Shangaan patients and traditional healers management strategies of hypertension in Limpopo Province

The study explored the cultural care beliefs, values and attitudes of Shangaans patients' and traditional healers' management strategies of hypertension in the Limpopo Province. The study aimed to describe the cultural values, beliefs and practices including taboos, rituals and religion within the world-view of the Shangaans. The study was undertaken in the Mopani region of the Greater Giyani area, with the purpose of recommending improvements to patient care in this area. Data collection was done by conducting focus groups and individual interviews. The following themes emerged. Hypertension. The traditional healer: the instrumental role. Traditional medicine versus Western medicine. Magico-religious healings. Cultural beliefs of Shangaans and hypertension. Experiences of hypertensive patients with regard to traditional healers and hypertension.

Microbial exopolymers link predator and prey in a model yeast biofilm system

Protistan grazing on biofilms is potentially an important conduit enabling energy flow between microbial trophic levels. Contrary to the widely held assumption that protistan feeding primarily involves ingestion of biofilm cells, with negative consequences for the biofilm, this study demonstrated preferential grazing on the noncellular biofilm matrix by a ciliate, with selective ingestion of yeast and bacterial cells of planktonic origin over attached and biofilm-derived planktonic cells. Introducing a ciliate to two biofilm-forming Cryptococcus species, as well as two bacterial species in a model biofilm system, fluorescent probes were applied to determine ingestion of cellular and noncellular biofilm fractions. Fluoromicroscopy, as well as photometric quantification, confirmed that protistan grazing enhanced yeast biofilm metabolism, and an increase in biofilm biomass and viability. We propose that the extracellular polymeric matrix of biofilms may act as an interface regulating interaction between predator and prey, while serving as source of nutrients and energy for protists.

Neoadjuvant chemotherapy for locally advanced carcinoma of the lower oesophagus and oesophago-gastric junction

AIMS

To evaluate a single unit's experience with neoadjuvant chemotherapy for treating locally advanced non-metastatic initially resectable and unresectable oesophago-gastric cancer.

METHODS

The medical records of all patients with either locally advanced carcinoma of the lower oesophagus or cardia treated with neoadjuvant chemotherapy between August 1999 and January 2003 were reviewed.

RESULTS

Sixty-four patients with initially resectable tumours (T2-3 or N+) and 38 patients with initially unresectable tumours (T4 or M1a) received neoadjuvant chemotherapy (83% combination Epirubicin, Cisplatin and 5-Fluorouracil). Symptomatic grade III/IV toxicity was observed in 33% of patients. Chemotherapy was not completed in 20 patients because of death (5.9%) and inadequate tumour response/toxicity (13.7%). Forty-three patients (67.3%) with initially resectable tumours and 19 patients (50%) with initially unresectable tumours underwent surgery.

CONCLUSIONS

Chemotherapy in this study was associated with appreciable toxicity. Patients with initially unresectable locally advanced disease can be downstaged with neoadjuvant chemotherapy.

Response of the microbial community to copper oxychloride in acidic sandy loam soil

AIMS

Determining the response of different microbial parameters to copper oxychloride in acidic sandy loam soil samples using cultivation-dependent and direct microscopic techniques.

METHODS AND RESULTS

Culturable microbial populations were monitored for 245 days in a series of soil microcosms spiked with different copper oxychloride concentrations. Microbial populations responded differently to additional Cu. Protistan numbers and soil metabolic potential decreased. Experiments with more soil samples revealed that metabolic potential was not significantly affected by < or =100 mg kg(-1) additional Cu. However, a negative impact on protista was noted in soil containing only 15 mg kg(-1) EDTA-extractable Cu. The negative impact on protistan numbers was less severe in soils with a higher phosphorous and zinc content.

CONCLUSIONS

Bacterial populations responded differently, and protista were most sensitive to elevated Cu levels. Protistan numbers in soil from uncultivated land were higher and seemed to be more sensitive to additional Cu than the numbers of these organisms in soil originating from cultivated land.

SIGNIFICANCE AND IMPACT OF THE STUDY

Protistan sensitivity to small increases in Cu levels demonstrates the vulnerability of the soil ecosystem to Cu perturbations, especially when the importance of protista as link in the flow of energy between trophic levels is considered.

Shifts in community composition provide a mechanism for maintenance of activity of soil yeasts in the presence of elevated copper levels

Soil dilution plates were prepared from different soil samples using a solid synthetic selective medium containing (i). glucose as carbon source, (ii). thymine as nitrogen source, (iii). vitamins, (iv). minerals, and (v). chloramphenicol as antibacterial agent. Using the Diazonium Blue B colour reaction, it was found that both ascomycetous and basidiomycetous yeasts were able to grow on this medium. Subsequently, the medium was used to enumerate yeasts in soil microcosms prepared from four different soil samples, which were experimentally treated with the fungicide copper oxychloride, resulting in copper (Cu) concentrations of up to 1000 ppm. The selective medium supplemented with 32 ppm of Cu was used to enumerate Cu-resistant yeasts in the microcosms. The results showed that the addition of Cu at concentrations >or=approximately 1000 ppm did not have a significant effect on total number of yeasts in the soil. Furthermore, it was found that Cu-resistant yeasts were present in all the soil samples, regardless of the amount of Cu that the soil was challenged with. At the end of the incubation period, yeasts in the microcosms with zero and approximately 1000 ppm of additional Cu were enumerated, isolated, and identified with sequence analyses of the D1/D2 600-650 bp region of the large subunit of ribosomal DNA. Hymenomycetous species dominated in the control soil, while higher numbers of the urediniomycetous species were found in the soil that received Cu. These observations suggest that urediniomycetous yeasts may play an important role in re-establishing overall microbial activity in soils, following perturbations, such as the addition of Cu-based fungicides.

Possible absence of Helicobacter pylori in the early stages of duodenal ulceration

BACKGROUND

Helicobacter pylori is thought to be a cause of duodenal ulceration, but there is some evidence that it is found less often in early than in later disease.

AIM

To assess the presence of H. pylori in patients undergoing endoscopy for dyspepsia, with respect to their duration of symptoms.

DESIGN

Retrospective case note review.

METHODS

Patients were categorized as having a history greater or less than 6 months, and as H. pylori-positive or -negative, using biopsy rapid urease, culture and PCR tests.

RESULTS

Thirty-two duodenal ulcer patients with a history >6 months were all H. pylori-positive according to the PCR test; the five with a shorter history were H. pylori-negative. No patient H. pylori-negative by PCR was positive by the other tests.

DISCUSSION

H. pylori was (at least) less commonly present before 6 months. It is possible that H. pylori, although nearly always present after 6 months, is not present at the onset of the disease. Confirmation of this finding would imply that infection with the organism is not the cause of duodenal ulceration, but a factor producing recurrence and chronicity.

Morphological and histochemical observations of the organic components of ostrich eggshell

The organic component of the avian eggshell can be divided into 3 portions, the shell membranes, the matrix and the cuticle. These have been well characterised in the chicken but little has been published with regard to the ostrich (Struthio camelus). A number of recent studies have indicated that the cause of intra-shell embryonic deaths in the ostrich is similar to intra-shell embryonic deaths that occur in the chicken. These deaths in the chicken are associated with the loss of or damage to the waxy cuticle and other organic components of the eggshell, which is reported to be absent in the ostrich eggshell. In this study, preliminary morphological and histochemical analyses, at the level of the light and electron microscope, have characterised the various organic components of the ostrich eggshell. The results of the histochemical and electron microscopical analyses suggest that there may only be 1 shell membrane in this species, which could play a major role in the limitation of bacterial penetration to the embryonic chamber The shell membrane has a distinct elemental profile as determined by EDS analysis. The matrix is shown to decrease in mesh size from the mammillary layer to the vertical crystal layer. The closer packing of the mesh may indicate the presence of a morphologically discernible termination signal to calcification or the remnants of an evolutionary calcified cuticle. The matrix of the pores may also form a defensive barrier against bacterial invasion, which could be damaged as a result of dipping the eggs before incubation.

Bioprospecting for novel oxylipins in fungi: the presence of 3-hydroxy oxylipins in Pilobolus

As previously found in various members of the Mucorales, 3-hydroxy oxylipins in Mucor genevensis are associated with the sporangia, i.e. mainly the columella structure and between aggregating sporangiospores. To determine if this phenomenon is also true in distantly related members, the mucoralean fungus Pilobolus was examined. This fungus is characterized by relatively large sub sporangial-columella structures which actively eject sporangia in a sticky liquid for attachment onto herbage surrounding its growth medium--in this case horse dung. Strikingly, this fungus produced a novel oxylipin i.e. a 3-hydroxy monounsaturated fatty acid, possibly a nonenoic acid, which is mainly associated with the sub sporangial-columella structure and aggregating sporangiospores. The specificity of the antibody against 3-hydroxy oxylipins used in immunofluorescence mapping of the mucoralean fungi, was further confirmed in the yeast, Saccharomycopsis malanga which produces 3-hydroxy palmitate in crystal form. These crystals occur between aggregating yeast cells. On the basis of the available data, we hypothesize that 3-hydroxy oxylipins probably function as adhesives, attaching fungal cells to each other or to other surfaces through entropic based hydrophobic forces and/or hydrogen bonds.

Mapping the distribution of 3-hydroxylipins in the Mucorales using immunofluorescence microscopy

The distribution of endogenous 3-hydroxylipins (3-OH oxylipins) in representatives of the Mucorales was mapped using immunofluorescence microscopy. Strains of each of the following genera were examined: Absidia, Actinomucor, Cunninghamella, Mortierella (subgenus Micromucor), Mortierella (subgenus Mortierella), Mucor and Rhizomucor. Immunofluorescence microscopy was carried out using an antibody that was raised against 3R-hydroxy-5Z,8Z, 11 Z, 14Z-eicosatetraenoic acid (3R-HETE), which cross-reacts with other 3-OH oxylipins. Subsequently, the occurrence and distribution of the antibody on the various reproductive stages of each fungus was noted. In Absidia, Actinomucor, Mortierella (subgenus Micromucor), Mucor and Rhizomucor, 3-OH oxylipins were found to be associated with the columellae and/or wall of the sporangium. In the representative of Cunninghamella, the 3-OH oxylipins were associated with the single-spored sporangiola. No 3-OH oxylipins were detected in the strains representing Mortierella (subgenus Mortierella).

A novel oxylipin-associated 'ghosting' phenomenon in yeast flocculation

Research on the distribution of oxylipins (3-hydroxy fatty acids) in flocculant strains of the yeast Saccharomyces cerevisiae led to the uncovering of a novel 'ghosting' phenomenon observed during assumed lectin-mediated aggregation. We found that intracellular oxylipin-containing osmiophilic layers migrate through yeast cell walls in a 'ghostlike' fashion without visually affecting the cell wall structure or the layers. This migration resulted in the binding of these layers to cell walls of adjacent cells. Consequently, 'ghosting' seems a prerequisite for flocculation to occur. However, 'ghosting' alone may not be sufficient to ensure flocculation.

An isolation procedure for arachidonic acid producing Mortierella species

Malt extract agar and an incubation temperature of 5 degrees C were used to selectively isolate representatives of the genus Mortierella from soil. Fungi in a soil sample from mountain grassland able to grow under these conditions, amounted to a total of 2640 colony forming units per gram soil. Circa 94% of the total fungal isolates represented Mortierella subgenus Mortierella. The rest of the colony-forming units consisted of Mucor isolates (6.0%) and higher fungi (1.5%). All the Mortierella isolates produced arachidonic acid.

Oxylipin formation in fungi: biotransformation of arachidonic acid to 3-hydroxy-5,8-tetradecadienoic acid by Mucor genevensis

The soil fungus Mucor genevensis was shown to convert exogenous arachidonic acid to the oxylipin 3-hydroxy-5Z,8Z-tetradecadienoic acid (3-HTDE) as determined by gas chromatography/mass spectrometry. This metabolite was only found in the aqueous supernatant together with free linoleic acid, but not in the final fungal biomass. In contrast, the corresponding primary arachidonic acid metabolite (3R)-hydroxy-(5Z,8Z,11Z,14Z)-eicosatetraenoic acid (3-HETE), which has been earlier shown to be produced by the yeast Dipodascopsis uninucleata, could not be detected. These observations may be plausibly explained by a retroconversion by M. genevensis of arachidonic acid to linoleic acid before the latter is metabolised to 3-HTDE.

Helicobacter pylori: the mouth, stomach, and gut axis

The aim of this study was to identify the natural reservoir and route of transmission of Helicobacter pylori infection. Two hundred eight (208) dyspeptic patients (114 males, 94 females; peak age of cohort, 50-59.9) were recruited. Specimens were collected from saliva, supra- and subgingival dental plaque, tongue scrapings, and oropharyngeal swabs. At subsequent endoscopy, gastric antral biopsy was performed for the rapid urease test (RUT), microbiological culture, and, in some patients, histology. Gastric juice samples were aspirated, and in 50 patients duodenal aspirate was collected. Polymerase chain reaction (PCR) with primers targeted to the 16S rRNA sequence of H. pylori was also employed for each of the specimens. In those patients where H. pylori was detected from multiple sites (dental plaque, gastric juice, gastric biopsy, and duodenal aspirate), restriction endonuclease digestion with Hae III was performed to determine if they were epidemiologically linked. The results indicated that 15/208 patients (7%) tested positively for H. pylori by PCR in dental plaque; only 2 samples were positive by culture. In none of the other oral sites sampled was H. pylori detected by any test used in the study. Gastric juice and gastric biopsy specimens from 36/ 208 patients (17%) and 114/208 patients (55%), respectively, were positive by PCR. Duodenal aspirate from 6/50 patients (12%) also tested positively by PCR. All specimens tested by restriction endonuclease digestion with Hae III (15/15 patients) were positive in both antral biopsy and gastric juice specimens, as well as 5 specimens from the duodenal aspirate. Four of the dental plaque strains had restriction patterns similar to those of the stomach and duodenal sites, providing evidence that these sites were infected with the same strain of H. pylori. In conclusion, the results suggest that H. pylori selects the gastric mucosa as its preferred site. The detection in dental plaque could indicate that the oral cavity may act as a reservoir or sanctuary for the organism. Whether H. pylori is a resident or transient oral microorganism is still unclear, although it is more likely to be transient in nature.