Surgeon's Experience May Circumvent Operative Volume in Improving Early Outcomes After Pancreaticoduodenectomy

Introduction Pancreaticoduodenectomy (PD) is a complex procedure with a significant proportion of postoperative complications and improving but notable mortality. PD was the prototype procedure that initiated the lingering debate about the relationship of better operative outcomes when performed at higher-volume centers. This has not translated into practice. Impediments include the absence of a universally accepted definition of a high-volume center among others. Contrary evidence suggests equivalent outcomes for PD at low-volume centers when performed by experienced hepatobiliary surgeons. We reviewed our perioperative outcomes for PD from an earlier period as a low-volume center with an experienced team. Methods A longitudinal study of all PDs completed in our department between 2012 and 2017 was performed. Results A total of 28 PD were performed during this period. Pylorus-preserving PD was performed in 23 patients and classical PD in the remaining. A separate Roux-en-Y loop was used for high-risk pancreatic anastomosis in six cases. The mean patient age was 49.3±12.4 years. The male-to-female ratio was 1.3:1. Preoperative drainage procedures were carried out in 19 patients. The mean serum total bilirubin level was 3.98(±4.5) mg/dL. There was no 90-day mortality. Postoperative complications included wound infection in 10 (36.7%) and respiratory complications in 10 (36.7%) patients. Postoperative bleeding requiring intervention occurred in one patient, and two patients had an anastomotic leak (one pancreatojejunostomy (PJ) and one gastrojejunostomy (GJ)). Delayed gastric emptying (DGE) was noted in three (10.7%) patients. The mean length of hospital stay was 14±7 days. The median overall survival (OS) was 84 months. Conclusion Comparable early outcomes can be achieved at low-volume centers for patients undergoing PD with an experienced team, optimal patient selection, and the ability to rescue for complications.

Community- vs. hospital-based management of multidrug-resistant TB in Pakistan

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

Preoperative heart rate and myocardial injury after non-cardiac surgery: results of a predefined secondary analysis of the VISION study

Background

Increased baseline heart rate is associated with cardiovascular risk and all-cause mortality in the general population. We hypothesized that elevated preoperative heart rate increases the risk of myocardial injury after non-cardiac surgery (MINS).

Methods

We performed a secondary analysis of a prospective international cohort study of patients aged ≥45 yr undergoing non-cardiac surgery. Preoperative heart rate was defined as the last measurement before induction of anaesthesia. The sample was divided into deciles by heart rate. Multivariable logistic regression models were used to determine relationships between preoperative heart rate and MINS (determined by serum troponin concentration), myocardial infarction (MI), and death within 30 days of surgery. Separate models were used to test the relationship between these outcomes and predefined binary heart rate thresholds.

Results

Patients with missing outcomes or heart rate data were excluded from respective analyses. Of 15 087 patients, 1197 (7.9%) sustained MINS, 454 of 16 007 patients (2.8%) sustained MI, and 315 of 16 037 patients (2.0%) died. The highest heart rate decile (>96 beats min⁻¹) was independently associated with MINS {odds ratio (OR) 1.48 [1.23–1.77]; P<0.01}, MI (OR 1.71 [1.34–2.18]; P<0.01), and mortality (OR 3.16 [2.45–4.07]; P<0.01). The lowest decile (<60 beats min⁻¹) was independently associated with reduced mortality (OR 0.50 [0.29–0.88]; P=0.02), but not MINS or MI. The predefined binary thresholds were also associated with MINS, but more weakly than the highest heart rate decile.

Conclusions

Preoperative heart rate >96 beats min⁻¹ is associated with MINS, MI, and mortality after non-cardiac surgery. This association persists after accounting for potential confounding factors.

Clinical trial registration

NCT00512109.

Influence of the presence of Zymomonas anaerobia on the conversion of cellobiose, glucose, and xylose to ethanol by Clostridium saccharolyticum

To convert sugar mixtures containing cellobiose, glucose, and xylose to ethanol in a single step, the possibility of using a coculture consisting of Clostridium saccharolyticum and Zymomonas anaerobia was studied. In monoculture, C. saccharolyticum utilized all three sugars; however, it preferentially utilized glucose and produced acetic acid in addition to ethanol. The formation of acetic acid from the metabolism of glucose inhibited the growth of C. saccharolyticum and, consequently, the utilization of cellobiose and xylose. In monoculture, Z. anaerobia utilized glucose at a rate of 50 g/L day, but it did not ferment cellobiose or xylose. In coculture, Z. anaerobia converted most of the glucose to ethanol during the lag phase of growth of C. saccharolyticum, which then converted cellobiose and xylose to ethanol. The use of this coculture increased both the rate and the efficiency of the conversion of these three sugars to ethanol, and produced relatively small amounts of acetic acid.

Day case Laparoscopic Cholecystectomy: experience at the Bangabandhu Sheikh Mujib Medical University

Day case surgery offers convenience to the patients and cost saving to the healthcare institutes. In this prospective study, the authors reviewed their experience with day case Laparoscopic Cholecystectomy (LC) to determine its outcome in the government healthcare settings of Bangladesh. Selection criteria's for the day case LC were patients with symptomatic cholelithiasis with ASA (American Society of anesthesiologists) grade I or II, the availability of a responsible carer, absence of morbid obesity, low risk for concomitant presence of bile duct stones and domicile within Dhaka and around. Patients were admitted in the post operative ward as day case (DC) in the morning and were discharged on the next morning with a standard analgesia. Two hundred ten patients were admitted for LC as day cases over the last 7 years from October 2003 to October 2010 on the morning operation theatre lists. Five patients later required admission to the inpatient department for conversion to the open procedure. None of the patients was readmitted after discharge. Majority patients were followed up after 1st and 6th week. Two hundred seven patients attended for the follow up at the 1st week and 158 patients were reported for the 6th week. One hundred ninety six patients resumed their normal job or activities after one week. Patient's satisfaction was assessed by questionnaires. Two hundred five patients were either satisfied or very satisfied with the day-case procedure. It appears that for selected groups of patients, day-case LC can be safely done in government healthcare settings of Bangladesh with good patient satisfaction.

Endoscopic para-thyroidectomy: a new approach

Two patients (one male and one female) underwent endoscopic para-thyroidectomy for parathyroid adenoma at the Department of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Three ports (one mid line and two laterals) were employed, a 10 mm telescope was used for the visualization and a harmonic scalpel was used for the dissection. To the best of our knowledge, there was no report of endoscopic para-thyroidectomy from Bangladesh. Both patients were fed on the first post operative day and discharged from the 4th and 8th operative day. Both patient's parathyroid hormone (PTH) level dropped to about one fourth the level in 12 to 20 minutes after enucleation (as compared to the immediate pre operative level). Endoscopic para-thyroidectomy appears to be a technically feasible patient friendly modality of treatment for the selected cases of para-thyroid pathology in experienced hand with excellent cosmetic outcome.

Fermentative conversion of cellulose to acetic Acid and cellulolytic enzyme production by a bacterial mixed culture obtained from sewage sludge

A simple procedure that uses a cellulose-enriched culture started from sewage sludge was developed for producing cellulolytic enzymes and converting cellulose to acetic acid rather than CH(4) and CO(2). In this procedure, the culture which converts cellulose to CH(4) and CO(2) was mixed with a synthetic medium and cellulose and heated to 80 degrees C for 15 min before incubation. The end products formed were acetic acid, propionic acid, CO(2), and traces of ethanol and H(2). Supernatants from 6- to 10-day-old cultures contained 16 to 36 mM acetic acid. Cellulolytic enzymes in the supernatant were stable at 2 degrees C under aerobic conditions for up to 4 weeks and had the ability to hydrolyze carboxymethyl cellulose, a microcystalline cellulose, cellobiose, xylan, and filter paper to reducing sugars.

Life in conflict: Characteristics of Depression in Kashmir

BACKGROUND

Mental, physical and social health, are vital strands of life that are closely interwoven and deeply interdependent. Mental disorders affect people of all countries and societies, individuals at all ages, women and men, the rich and the poor, from urban and rural environments. Depression is more likely following particular classes of experience - those involving conflict, disruption, losses and experiences of humiliation or entrapment. Many people living amidst the rages of conflict suffer from post-traumatic stress disorder.

OBJECTIVE

To determine the characteristics of depression in the population in Kashmir where a low-intensity-conflict has been going on for the last seventeen years.

METHODS

The non-combatant civilian population was surveyed. The Centre for Epidemiological Studies Depression (CES-D) Scale was used to measure symptoms of depression in community populations.

RESULTS

Due to continuing conflict in Kashmir during the last 18 years there has been a phenomenal increase in psychiatric morbidity. The results reveal that the prevalence of depression is 55.72%. The prevalence is highest (66.67%) in the 15 to 25 years age group, followed by 65.33% in the 26 to 35 years age group. The difference in the prevalence of depression among males and females is significant. Depression is much higher in rural areas (84.73%) as compared to urban areas (15.26%). In rural areas the prevalence of depression among females is higher (93.10 %) as compared to males (6.8%).

CONCLUSION

Mental health is an integral part of overall health and quality of life. Effective evidence-based programs and policies are available to promote mental health, enhance resilience, reduce risk factors, increase protective factors, and prevent mental and behavioural disorders. Innovative community-based health programmes which are culturally and gender appropriate and reaches out to all segments of the population need to be developed. Substantial and sustainable improvements can be achieved only when a comprehensive strategy for mental health which incorporates both prevention and care elements is adopted.

Results of emergency appendectomy for appendicular mass

Emergency appendectomy was done on 1142 patients during the period of July 1990 to January 2003 to evaluate the results. Of which 656(57.44%) were male and 496(42.56%) were female. The mean age was 22.21+/-3.93 years (04-85 years). The duration of pain before admission was 3.05+/-0.94 days (01-17 days) and 708(62%) patients presented with palpable mass; ultrasonogram revealed additional lump in 114(9.98%) patients, rest of the lump (28.02%) was detected during operation. 342(30%) patients had appendix abscess and 228(19.96%) had loculated collection. Eight patients had tuberculosis and four had carcinoma in addition. All had appendicitis except two of which one patient had carcinoid tumor and one had enteric fever perforation. Operative time ranged from 15-85 minutes (29.38+/-3.19 minutes). The average hospital stay was 4.22+/-0.82 days (03-17 days). There was no failure, faecal fistula or death. The overall wound related complication was 22.86% of which 14.62% was very minor and overall intra abdominal complication was 4.12%. Persistent wound pain was in 43(3.87%) and hypertrophied scar was found in 05 (0.45%) patients. 05(0.45%) patients needed exploration for persistent sinus one of which was tuberculosis and remaining was due to suture material. Remote complications like RTI, UTI, and DVT was found in 04(0.35%) patients. There was no death, no faecal fistula and no failure. It seems that emergency appendectomy could safely be done in appendix mass without any increased risk of mortality and morbidity.

A prospective randomized trial of N-acetyl cysteine administration during cold preservation of the donor liver for transplantation

AIMS

N-acetyl cysteine (NAC), an anti oxidant and a glutathione precursor, is effective in ameliorating liver injury of Tylenol overdose. There is experimental evidence that it also reduces ischemia reperfusion (I/R) injury. This clinical study was undertaken to study the effect of NAC administered in the donor operation.

METHODS

22 patients were randomized to receive NAC (IV & Portal flush) or no NAC (Control Group) during donor operation. Peak AST levels and 1-hour post-reperfusion biopsies were used to assess I/R injury. Episodes of acute rejection were recorded together with immunosuppressive drug levels.

RESULTS

There were 4 exclusions (re-exploration for post-operative hemorrhage x3, OLT for acute liver failure x1). The two groups (n = 9 each) were matched for recipient and donor ages and sex. Viral hepatitis accounted for cirrhosis in 3 patients in NAC Group and 6 patients in Control Group. Statistically, Cold and warm ischemia times were not significantly different as was the use of blood and blood products in both groups. Serum peak AST levels were similar and post- reperfusion biopsy showed moderate to severe reperfusion injury in 3 recipients in the NAC Group and 4 in the Control Group. Excluding ones associated with low Tacrolimus levels (n = 4), there were 6 episodes of acute rejection (2- mild, 4- moderate) in the NAC Group and 5 in the Control Group (3- mild,1- moderate, 1- severe).

CONCLUSION

In this pilot study, NAC administered during donor operation did not show a protective effect on I/R injury or on acute cellular rejection.

Same admission colostomy closure: a prospective, randomised study in selected patient groups

BACKGROUND

Despite a recent trend towards primary repair, colostomy still has an important place in the management of different colorectal pathologies. Timing of colostomy closure is a debatable issue among general surgeons. We carried out a prospective, randomised study to compare the outcome after same admission colostomy closure (SACC) and conventional delayed colostomy closure (CDCC) in patients with predominantly traumatic injury of the large bowel.

METHODS

Sixty patients, the majority with traumatic colorectal pathologies, were prospectively randomised to SACC [30 patients, 23 men, mean age 27.9 +/- 9.7 (range, 18-65) years] or (CDCC) [30 patients, 24 men, mean age 28.6 +/- 10.6 (range, 18-63) years]. All colostomies were closed using an intraperitoneal closure technique. Pre-operative data and post-operative outcomes were collected and analysed.

RESULTS

A total of seven patients (23.3%) with SACC developed complications compared with eight patients (26.6%) having CDCC (p = 0.83). The mean hospital stay (p < 0.01), as well as the overall cost (p < 0.001), were significantly less in the SACC group.

CONCLUSIONS

Same admission colostomy closure is a safe and cost-effective technique for colostomy closure in selected groups of patients.

Prevalence of chronic suppurative otitis media among the children living in two selected slums of Dhaka City

Chronic Suppurative Otitis Media (CSOM) is one of the important health problems in our country. Serious complications may arise from it. As such the study was aimed to find out the prevalence of CSOM among the children of two-selected slum dwellers in Dhaka City. This was a descriptive type of cross-sectional study. A total of 203 samples were interviewed and examined. Altogether 7.39% of children were observed to have CSOM. Among CSOM cases, 60% had hearing impairment. Ear discharge and perforation were observed in 26.7% in right ear, 46.7% in left ear and 26.7% in both ears. Central perforation was present in 93% cases. Cholesteatoma was present in 6.7% cases. Among CSOM cases, 53.3% children were in 2-5 years age group, 80% were dependent, 53.3% cleaned ear by cotton buds, 93.3% lived in Kutcha house, 73.3% had a monthly income of TK. 1001-2000 and 46.7% belonged to families having 6 members. Out of 15 CSOM, 11 cases were seen among children of 141 illiterate mothers. Four cases of CSOM were found among children of 62 literate mothers. Among the 203 mothers, 65.52% were found aware, and 34.48% were not aware about the disease and sequel of CSOM. Here 39.9% mothers had knowledge and 60.01% had no knowledge about the treatment of CSOM. Among the CSOM cases 46.67% cases did not receive any treatment. In treatment receiving group, only 3(20%) children received it from MBBS doctor or Hospital.

Evaluation of the POSSUM scoring system for comparative audit in pancreatic surgery

BACKGROUND

Wide variations exist in the reported morbidity and mortality rates for major pancreatic resections. The Physiological and Operative Scoring System for enUmeration of Morbidity and mortality (POSSUM) was developed for comparative audit in general surgical patients. It has also been found to be reliable for audit in colorectal, thoracic and vascular surgery with minor modifications.

AIMS

To evaluate POSSUM and its modification for mortality, P-POSSUM, in pancreatic surgery.

METHODS

Retrospective analysis of 50 patients undergoing partial pancreaticoduodenectomy (PD) (46 tumours, 4 chronic pancreatitis) using the POSSUM and P-POSSUM as predictors of morbidity and mortality. These were then compared with the observed values.

RESULTS

The POSSUM-predicted mortality was 26%. The P-POSSUM predicted a mortality risk of 6%. The observed mortality was 4%. Using POSSUM for morbidity, the predicted value was 76%. The observed morbidity was 46%. The risk scores for patients with and without morbidity were similar (66.4 +/- 11.0 vs. 68.8 +/- 12.9, p = 0.49).

CONCLUSIONS

While P-POSSUM appeared satisfactory for predicting mortality risk, POSSUM overestimated morbidity and mortality for PD in a specialist centre. Modifications are needed prior to its application for comparative audit in pancreatic surgery.

Isolated Roux Loop duct-to-mucosa pancreaticojejunostomy avoids pancreatic leaks in pancreaticoduodenectomy

BACKGROUND

Over the last decade the operative mortality associated with pancreaticoduodenectomy (PD) has decreased. Pancreatic anastomotic leaks resulting in pancreatic bed sepsis and fistulae, however, remain a significant cause of both morbidity and mortality. The optimal method of reconstruction to minimise pancreatic leaks is controversial.

AIM

To review the experience of Roux loop duct-to-mucosa pancreaticojejunostomy in a consecutive series of patients undergoing pancreatic head resection.

METHODS

Over the 6-year period (1993-1998), 41 patients underwent pancreatic head resections for benign (n = 5) and malignant disease (n = 36). There were 19 males and the median age was 62 years (range 29-83). An isolated Roux loop pancreaticojejunostomy was performed in all cases.

RESULTS

Median duration of surgery was 8 h and the median postoperative stay was 16 days. The mean peri-operative blood transfusion was 2.9 units (SD 1.9). The incidence of major complications was 12% and there was 1 death (2.4%). There were no pancreatic leaks or fistulae.

CONCLUSIONS

The low complication rate and the absence of pancreatic fistulae in this series would suggest that Roux loop duct-to-mucosa pancreatic reconstruction should be more widely adopted.

Prognostic significance of intratumoural microvessel density (IMD) in resected pancreatic and ampullary cancers to standard histopathological variables and survival

AIM

Angiogenesis is required for tumour growth. Its evaluation, by intratumoural microvessel density (IMD), has prognostic significance in many solid tumours. There is controversy regarding its use in pancreatic cancer and little is known about its role in ampullary tumours. The aim is to study IMD as a prognostic marker in resected ductal adenocarcinomas of head of pancreas and cancers of the ampullary region.

METHODS

Forty-seven patients (23 pancreatic and 24 ampullary, mean age 62.0 years) surviving a potentially curative (R0/R1) resection were analysed. Paraffin-embedded sections of these tumours were immunohistochemically stained for CD-34 and IMD was determined (magnification x200). This was correlated with histopathological data and survival using Cox's multivariate analysis.

RESULTS

Mean survival for the pancreatic cancer group was 18.4 months (SE=2.7) and 81.2 months (SE=9.9) for the ampullary cancer group. In the pancreatic cancer group, IMD was found to have independent prognostic significance to survival on multivariate analysis (P=0.002, Hazard Ratio (HR) 13.60) along with microscopic resection margin involvement (P=0.003, HR 15.18). For ampullary cancers, IMD was higher in those with lymph node metastasis (P=0.02, Mann-Whitney U -test).

CONCLUSION

IMD in resected pancreatic cancers correlates with survival.

Liver tumours due to endometriosis and endometrial stromal sarcoma

BACKGROUND

Endometriosis can occur in unusual sites, liver involvement being first described in 1986. Extra-uterine malignant transformation in endometriosis has been reported, occurring mainly in the ovary. Liver involvement with endometrial stromal sarcoma (ESS) has not been previously reported.

CASE OUTLINE

Two patients presenting with symptomatic liver masses related to endometriosis, who successfully underwent surgical intervention, are presented.

CASE 1

A 31-year-old woman previously had been treated with hysterectomy and bilateral salpingoophorectomy for severe pelvic endometriosis. Six years later, she presented with malaise from bilobar liver involvement with endometrial deposits. She proceeded acutely to hilar obstruction with obstructive jaundice and portal vein thrombosis.

CASE 2

A 59-year-old post-menopausal woman had earlier presented acutely from a ruptured mesenteric cyst, which showed features of endometrial stromal sarcoma (ESS). Two years later, she presented with symptoms from a large ESS occupying the right lobe.

DISCUSSION

Endometriosis per se, as well as malignant transformation into ESS can involve the liver.These should be considered in women with hepatic space occupying lesions of unknown etiology.

A sustainable community-based arsenic mitigation pilot project in Bangladesh

A sustainable community-based arsenic mitigation pilot project has been successfully operating for 22 months in the Chapainawabganj arsenic hot spot (Bangladesh) where safe treated drinking and cooking water derived from tubewells is being supplied below the Bangladesh maximum permissible limit (0.05 ppm total arsenic). There has been close community involvement in all stages and the arsenic removal mechanism used adapted from the simple process of adsorption by natural ferric oxyhydroxide. Supplemented ferric oxyhydroxide produces daily de-contaminated water batches until replaced at the end of the cycle. A regional renewal/recycling centre supplies new, and safely stores used, ferric oxyhydroxide. Recycling is beginning where adsorbed arsenic can be separated prior to ferric oxyhydroxide reuse. The mechanism is flexible regarding water volumes, cycle lengths, pre and post-treatment arsenic concentrations, tubewell chemistries and is cost-effective. Pilot project parameters were set at 60 l per day ( < 0.05 ppm total arsenic) and 16 day cycles per tank for each of the four selected families with pretreatment concentrations up to 1.1 ppm. A maximum of ~ 24 g of arsenic is produced from the approximately 900 g (dry) of ferric oxyhydroxide used per tank per year. Anecdotal evidence possibly suggests positive health effects within a few months and villagers report an improved water taste. The project should contribute to coping with such arsenicosis crises and expansion is planned.

Hypertension and its determinants among adults in high mountain villages of the Northern Areas of Pakistan

We studied the prevalence and determinants of hypertension among adults in mountainous rural villages in the Ghizar district Northern Areas of Pakistan, an area that recently has undergone substantial economic development. We selected a stratified random sample of 4203 adults (age > 18 years) from 16 villages in Punial Valley of Ghizar district where the number of study subjects from each village was proportionate to the size of the village. We obtained blood pressure (BP) records by taking the mean of the second and third BP measurement, using a standard mercury sphygmomanometer, and assessed risk factors for hypertension in the study subjects. The mean +/- s.d. blood pressures (mm Hg) were 125 +/- 19 systolic and 80 +/- 12 diastolic in men and 125 +/- 22 systolic and 78 +/- 14 diastolic in women. The 125 +/- 22 systolic and 78 +/- 14 diastolic in women. The mm Hg, or systolic BP > or = 140 mm Hg or currently taking antihypertensive medication) was 15%, increasing from 4% in the 18-29 year age group to 36% among persons 60 years of age or older. The age-standardised prevalence of hypertension was 14% (12.5% among men and 14% among women). There was no significant difference in prevalence of hypertension in males, and in females. Multivariate analysis revealed that age, and higher body mass index (overweight and obesity) were independently associated with higher prevalence of hypertension. People with hypertension were more likely to have a first-degree relative with physician-diagnosed hypertension (OR = 1.90, 95% CI 1.49, 2). Hypertension is a significant health problem in rural northern Pakistan. The primary health care programme in the Northern Areas of Pakistan needs to address this problem, especially identifying people at risk.

Outpatient pediatric surgery in a developing country

OBJECTIVE

To access the prospects of daycare pediatric surgery in a developing country like Pakistan in view of economic advantages, parent's acceptability and utilization of hospital resources.

METHODS

This prospective study was carried out in Karachi from 1st January 1994 to 31st December 1996 in three different private hospitals having optimum operating, anaesthetic and recovery facilities. Selection criteria included general fitness for surgical procedure, not requiring hospitalization, no associated congenital malformation and co-operative parents residing in Karachi. An evening before surgery, all patients were examined thoroughly and detailed instructions for pre-operative fasting and pre-medications were given to the family. Operations were carried out by same surgical team with different set of anesthetists. After surgery and recovery from anesthesia, the children were observed in a holding area adjacent to operating room till fully conscious and alert. Before leaving the hospital, the parents were briefed about post-operative care at home like feeding, ambulation and use of analgesics. A contact telephone number was also provided to the family for any difficulty or emergency. All patients were re-examined 36-48 hours post-operatively in clinic, for any problem at home and the parents were assessed for their attitude toward this modality.

RESULTS

In 3-year period a total of 368 surgical procedures were carried out of whom 129 operations were done in children under 1-year of age and the youngest patient was one week old with a weight of 2.9 kg. The average age was 2.9 years and average weight was 13 kg. Male:female ratio was 3.6:1. The average operating time was 28 min, average anaesthesia time was 38 min and average recovery time was 17 min, which was not affected by the use of endotracheal tube. Majority of parents managed their children very well at home and only 17% of them called one of the surgeons to inquire about their apprehension at home and all were explained and satisfied. On an average 37% children required two doses of post-operative oral analgesia and 59% returned to normal activity after 24 hours. The overall incidence of complication was 3.6% and there were no deaths or major complications. Only one patient required post surgical hospitalization due to post-operative pneumonia. The mode of management was cost effective and also the parents appreciated the avoidance of hospitalization because of less disruption of their routine work at home and office.

CONCLUSION

Based on the above experience, we recommended that a variety of common pediatric operations can be done safely as out patients in infants and children, with economic advantages, high parent's acceptability and better utilization of hospital resources without scarifying the quality of health services.

Genetic and serovar typing of clinical isolates of the Mycobacterium avium-intracellulare complex

SETTING

One hundred and thirty-four Mycobacterium avium-intracellulare complex (MAC) isolates were obtained from 121 patients in the UK.

OBJECTIVE

To compare serotyping and genetic analysis for species identification of MAC isolates from patients with and without the acquired immunodeficiency syndrome (AIDS).

DESIGN

Clinical MAC isolates were cultured and analyzed by serotyping, the commercially available Accuprobe kit, hybridization with genes coding for the 19 kDa and 38 kDa antigens of M. tuberculosis and fingerprinting with the pMB22 probe derived from M. paratuberculosis.

RESULTS

Species classification on the basis of genetic analysis was similar to serovar typing, with only exceptional discrepancies. Serovar prevalence was different in the two groups of patients, and different from those reported in other countries. MAC isolates from AIDS patients were exclusively M. avium, whereas patients without AIDS had MAC infections with M. avium and M. intracellulare in about equal proportion. M. intracellulare clinical isolates were genetically more heterogeneous than M. avium. Only M. intracellulare hybridized with the 38 kDa gene probe.

CONCLUSIONS

Serovars are strongly linked with species in clinical MAC isolates, confirming results previously obtained with reference strains. M. intracellulare can be easily identified by the presence of a 38 kDa gene.

Transformation of sitosterol to androsta-1, 4-diene-3, 17-dione by immobilized Mycobacterium cells

Transformation of sitosterol to androsta-1, 4-diene-3, 17-dione was studied with Mycobacterium cells entrapped in various polymeric matrices. Of the three supports viz. alginate, carageenan, agarose and polyacrylamide, studied, the polyacrylamide immobilized cells showed optimum catalytic stability and reusability.

Cellulase and Sugar Formation by Bacteroides cellulosolvens , a Newly Isolated Cellulolytic Anaerobe

A newly isolated mesophilic anaerobe, Bacteroides cellulosolvens , has the ability to produce cellulase and to degrade cellulose to cellobiose and glucose. It does not utilize glucose, and it lacks β-glucosidase activity. This anaerobe appears to degrade cellulose to cellobiose by cellulase action, and the presence of cells appears necessary for the formation of glucose.

Cellulolytic enzyme system of Acetivibrio cellulolyticus

Polyacrylamide gel electrophoresis of the cellulolytic system from culture supernates of Acetivibrio cellulolyticus showed the presence of four major enzymes: a beta-glucosidase, an exoglucanase, and two endoglucanases. The relative proportions of these enzymes in the culture supernate were affected by the nature of the cellulosic substrate and by the length of the incubation period. The molecular weights of the cellulolytic enzymes were beta-glucosidase, 81 000; exoglucanase, 38 000; endoglucanase C2, 33 000; and endoglucanase C3, 10 400, as estimated by their electrophoretic mobilities relative to proteins of known molecular weight. Treatment of the high molecular weight endoglucanase with SDS--mercaptoethanol led to reversible dissociation of the enzyme into polypeptide subunits similar to the low molecular weight endoglucanase. Endoglucanase activity could be assayed for directly using a novel method of incorporating carboxymethyl cellulose in the polyacrylamide gels. The molecular weights and functions of these enzymes are compared with those detected in culture filtrates of various fungi.

Cellulose degradation by a new isolate from sewage sludge, a member of the Bacteroidaceae family

A mesophilic anaerobe, a member of the Bacteroidaceae family (NRC2248), isolated from a cellulose-enrichment culture, digested untreated Whatman cellulose powder and HCl-treated cotton battings while producing hydrogen, carbon dioxide, cellobiose, glucose, and acetic acid as the sole volatile acid. This organism also utilized cellobiose as carbon and energy source but did not utilize glucose. It grew well in synthetic medium containing ammonium salts as nitrogen source and having a pH value of 7.0-7.1 and an Eh value of -160mV or lower. The nutrient requirements of this organism were found to be similar to those of other anaerobes except for Na2S which inhibited cellulose degradation in concentrations above 0.75 mM. Best cellulose degradation occurred under an atmosphere of 80% N2-20% CO2. Use of H2 or 80% H2-20% CO2 as headspace gas inhibited growth. Although accumulation of acetic acid in about 15-16 mM concentrations inhibited the further formation of H2, CO2, and acetic acid in the broth, it did not stop the degradation of cellulose. The results indicate that this organism has the ability to grow in media containing up to 20 g/L of cellulose and to produce industrially important and easily separable end products from cellulose.

Effect of sulfur-containing compounds on anaerobic degradation of cellulose to methane by mixed cultures obtained from sewage sludge

Tests were made to determine the effects of inorganic and organic sulfur sources on the degradation of cellulose to methane in a chemically defined medium with sulfur-poor inoculum prepared from sewage sludge. The results show that a sulfur source of about a 0.85 mM concentration is essential for the degradation of cellulose to CH4. However, the production of CH4 from CO2 and H2 provided in the headspace occurred with 0.1 mM sulfate or sulfide. At a 9 mM concentration, all inorganic sulfur compounds other than sulfate inhibited both cellulose degradation and methane formation, and this inhibition increased in the order thiosulfate less than sulfite less than sulfide less than H2S. It appears that the degradation of cellulose to CH4 in a sulfate-free medium by inoculum maintained in a low-sulfur medium is inhibited because of the lack of availability of sulfur for growth of bacteria and synthesis of cell materials and sulfur-containing cofactors involved in cellulose degradation and methanogenesis. The reduction of methanogenesis by higher levels of sulfate probably occurs as a result of stimulation of reactions converting acetate and H2 to end products other than CH4.

Anaerobic degradation of cellulose by mixed culture

A mixed culture in which cellulose is capable of being converted to methane and carbon dioxide was obtained from an inoculum procured from a sewage-treatment plant and maintained in a synthetic medium containing tissue paper and an inorganic salt and vitamin mixture. The culture was tested for its ability to degrade 12 different paper and cotton products under batch conditions in 3-l anaerobic fermenters. This culture degraded 6-8 mmol/l per week of cellulose, expressed as glucose equivalents, with total gas yields of 0.3 m3/kg of cellulose degraded. The gas produced contained between 56 and 59% of methane. Maximum cellulose degradation occurred at chemical oxygen demand:nitrogen:phosphorus level of 80:5:1 and was adversely affected by high stirring rate. Also the presence of higher proportions of lignin in cellulose products adversely affected the ability of this culture to degrade cellulose.

Growth inhibition of enteric bacteria by Vibrio cholerae in nutrient media containing lactate, acetate, or citrate

In cross-streak tests on nutrient agar containing lactate, acetate, or citrate, the growth of certain enteric bacteria was inhibited by themselves or by Vibrio cholerae, or by both. This mimicked the activity of bacteriocins, but the phenomenon was attributable to the accumulation of carbonate and increased alkalinity of the media.