Bioaccumulation and trophic transfer of total mercury through the aquatic food webs of an African sub-tropical wetland system

Anthropogenic activities, including combustion of fossil fuels, coal, and gold mining, are significant sources of mercury (Hg) emissions into aquatic ecosystems. South Africa is a major contributor to global Hg emissions (46.4 tons Hg in 2018), with coal-fired power stations as the main source. Atmospheric transport of Hg emissions is the dominant cause of contamination, especially in the east coast of southern Africa where the Phongolo River Floodplain (PRF) is located. The PRF is the largest floodplain system in South Africa, with unique wetlands and high biodiversity, and provides essential ecosystem services to local communities who rely on fish as a protein source. We assessed the bioaccumulation of Hg in various biota, the trophic positions and food webs, as well as the biomagnification of Hg through the food webs from the PRF. Elevated Hg concentrations were found in sediments, macroinvertebrates and fish from the main rivers and associated floodplains in the PRF. Mercury biomagnification was observed through the food webs, with the apex predator tigerfish, Hydrocynus vittatus, having the highest Hg concentration. Our study shows that Hg in the PRF is bioavailable, accumulates in biota and biomagnifies in food webs.

Total mercury concentrations in sharks, skates and rays along the South African coast

Global declines in elasmobranch populations resulting from several stressors raises conservation concern. Additionally, apex predators bioaccumulate high concentrations of total mercury (THg), due to biomagnification. Although South Africa is considered one of the top ten contributors of Hg emissions globally, information on Hg concentrations in elasmobranchs is limited. The aim of this study was to evaluate the THg concentrations in 22 species of elasmobranchs along the South African coastline. Concentrations ranged between 0.22 and 5.8 mg/kg in Haploblepharus pictus (dark shysharks) and Rostroraja alba (white skates) on the south coast, respectively. Along the east coast it ranged between 0.21 and 17.8 mg/kg in Mobula kuhlii (shortfin devil rays) and Sphyrna lewini (scalloped hammerheads), respectively. Mercury concentrations on the east coast were in the same range or higher compared to the same species sampled between 2005-10 from the same region, with generally higher concentrations compared to the same species sampled globally.

OP0095 SINGLE-CELL RNA SEQUENCING REVEALS POTENT ANTI-INFLAMMATORY AND ANTIFIBROTIC ACTIVITIES OF DIMETHYL-ALPHA-KETOGLUTARATE ON EXPLANTED SKIN FROM PATIENTS WITH SYSTEMIC SCLEROSIS

Background

Activated fibroblasts are the main drivers of skin fibrosis in SSc. We have recently identified dimethyl alpha-ketoglutarate (dm-aKG) as a potential repressor of myofibroblast differentiation and profibrotic activity in cultured skin fibroblasts.

Objectives

To further analyse the clinical translation of our findings by investigating the antifibrotic capacity of dm-aKG on explanted skin biopsies from SSc patients.

Methods

We cultured forearm punch skin biopsies from SSc patients (n=10) for 24h ex vivo in the presence/absence of 6 mM dm-aKG. Thereafter, skin biopsies (n=4) were dissociated into single cells using a combined mechanical-enzymatic dissociation protocol, followed by single cell (sc)RNA-seq library preparation (10x Genomics) and sequencing (Illumina, NovaSeq6000, 50,000 reads/cell). We mapped the scRNA-seq reads to the reference genome GRCh38.p13 and analysed the data with R/Bioconductor tools. We deconvoluted cell types in bulk skin transcriptomes from SSc cohorts (GSE: 45485, 59785, 9285, 32413) using human skin scRNA-seq data1. The secretion of IL-6, procollagen-1, PRO-C1 (N-terminal type I collagen pro-peptide), C1M (MMP-degradation fragment of type I collagen), and fibronectin (FBN-C) from cultured skin (n=10) was measured in supernatants by ELISA. We analysed gene and protein expression in TGFβ-activated healthy and SSc dermal fibroblasts (DF, n=10) treated or not with dm-aKG using qPCR, Western blot and ELISA. Contractile properties of DF were assessed by gel contraction assay. Traction forces generated by DF were determined by reference-free traction force microscopy.

Results

Dissociated cultured SSc skin exhibited comparable cell yield and viability in the presence (20,203; 89%) and absence (25,280; 93%) of dm-aKG, respectively. scRNA-seq skin analysis included 20,869 high quality single cell profiles segregating into 10 distinct skin cell populations (Figure 1A). This analysis demonstrated decreased proportion of fibroblasts and increased proportion of keratinocytes in dm-aKG treated skin (p<0.05; Figure 1B). Among skin cell types, skin fibroblasts exhibited the largest amount of differentially expressed genes upon dm-aKG treatment (44%, n=779, x-fold>0.5, FDR<0.05), suggesting that these cells are key targets of dm-aKG therapy in SSc skin. We identified inflammatory/cytokine signalling (hub genes IL6, STAT1) and extracellular matrix (ECM) organization (hub genes MMP1, ITGB3) as top downregulated biological processes in fibroblasts in dm-aKG treated SSc skin (Figure 1C), coinciding with a decreased abundance of proinflammatory skin fibroblast subpopulation. Specifically, these cells were identified as the main source of IL6 (Figure 1D) and were enriched in SSc skin as revealed by deconvolution analysis of skin transcriptomes. Furthermore, dm-aKG reduced the secretion of IL-6, procollagen-1 and C1M, but not pro-C1 and FBN-C, from cultured skin explants. In cultured DF, dm-aKG blocked the inflammatory (IL-6, pSTAT3), profibrotic (aSMA, Fibronectin, Procollagen-1, Pro-C1) and contractile activities, and significantly diminished traction forces exerted by DF on the matrix substrate.

Figure 1.

scRNA-seq – comparison of untreated and dm-aKG treated paired skin biopsies. (A) UMAP plot with annotated skin cells, (B) differential abundance of main skin cell types, (C) volcano plot of DE genes with top downregulated gene ontology (GO) pathways in dm-aKG treated skin fibroblasts, (D) IL6 expression in untreated (blue) and treated (pink) skin fibroblasts.

Conclusion

Dm-aKG broadly interferes with inflammatory and ECM organizational activities of skin fibroblasts in culture and in explanted skin from SSc patients. These results confirm that dm-aKG might represent a potential new therapeutic approach for efficient targeting of skin inflammation and fibrosis in SSc.

References

[1]He H et al. J Allergy Clin Immunol 2020

Acknowledgements

This work was supported by a research grant from FOREUM Foundation for Research in Rheumatology and University Medical Centre Ljubljana.

Disclosure of Interests

Blaž Burja: None declared, Dominique Paul: None declared, Reto Gerber: None declared, Sam G. Edalat: None declared, Muriel Elhai Speakers bureau: BMS, Elena Pachera: None declared, Rahel S. Zingg: None declared, Francesca Michela Pramotton: None declared, Sofie Falkenløve Madsen: None declared, Kristina Buerki: None declared, Giampietro Costanza: None declared, Michael Whitfield: None declared, Anne-Christine Bay-Jensen: None declared, Snežna Sodin-Šemrl: None declared, Matija Tomsic: None declared, Gabriela Kania: None declared, Hubert Rehrauer: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Ziga Rotar: None declared, Mark Robinson: None declared, Katja Lakota: None declared, Mojca Frank Bertoncelj: None declared.

Biomarkers in tigerfish (Hydrocynus vittatus) as indicators of metal and organic pollution in ecologically sensitive subtropical rivers

Studies have shown high levels of contamination of both metals and organochlorine pesticides (OCPs) in aquatic systems of the world renowned Kruger National Park, South Africa. With effects evident in top predators, including, unexplained Crocodylus niloticus deaths and organ level and histological changes in Hydrocynus vittatus. A suite of biomarkers reflecting exposure and were selected to evaluate biological responses of H. vittatus to anthropogenic stressors as well as to evaluate whether the chosen suite of biomarkers could successfully distinguish between the different pollution profiles present in the selected rivers. During this study a clear relationship was found between exposure to environmental contaminants and the concomitant responses of H. vittatus to these stressors. The ensuing biomarker responses indicated that there is a physiological attempt to deal with, and mitigate the deleterious effects that metals and OCPs may induce. In the Luvuvhu River there is a clear indication in H. vittatus of the stimulation of anti-oxidant protective mechanisms in response to internal OCP exposure. This is reflected by the increasing cytochrome P-450, superoxide dismutase, and more specifically reduced glutathione, which resulted in decreased lipid and protein breakdown (reflected in decreased lipid peroxidation and protein carbonyl levels). Consequently H. vittatus populations of the Luvuvhu River are under greater cumulative stress and this is reflected in the lower energy budgets. Our results further show the integrated application value of the current suite of biomarkers in assessing responses of subtropical fish to metal and OCP exposure as the entire suite of biomarkers when used in conjunction were able to explain 100% of the variation in the data.

A Multivariate Analysis of Metal Concentrations in Two Fish Species of the Nyl River System, Limpopo Province, South Africa

Increased toxicity due to high metal concentrations may hinder the ecological integrity of aquatic ecosystems in sustaining life. The non-biodegradable nature of metals may result in bioaccumulation in aquatic organisms. Due to ecological and social aspects it is imperative for monitoring schemes to identify possible impacts to the systems integrity. This paper discusses accumulation patterns of seven metals (Al, Cr, Cu, Fe, Mn, Sr and Zn) in tissues of two fish species, namely Clarias gariepinus and Oreochromis mossambicus at two selected sites, the first located upstream of Modimolle (NRS1), and the second located downstream of the town (NRS2). Gills, liver, muscle and skin tissues were analysed for metal concentrations using standard microwave digestion and inductively coupled plasma mass spectrometry techniques. Statistical results indicated higher concentrations of metals at NRS2 in comparison to NRS1, indicating that Modimolle plays a potential role in introducing metals into the aquatic system.

Real-world evaluation of TNF-inhibitor utilization in rheumatoid arthritis

OBJECTIVES

To evaluate 12-month treatment patterns, healthcare resource use (HCRU), and costs for patients with rheumatoid arthritis (RA), following initiation of index TNF inhibitors (TNFi) and subsequent biologic DMARDs (bDMARDs).

METHODS

This was a retrospective cohort analysis of adults with RA newly initiating TNFi in the Truven Marketscan Commercial Claims and Encounters and Medicare Supplemental Databases during 2010-2013. A sub-group of patients who switched to a bDMARD within 12 months post-index and within 180 days of last index TNFi were subsequently evaluated over 12 months. TNFi/bDMARD treatment patterns were characterized as: continuers, no gap >180 days in prescription/administration of index TNFi; discontinuers, gap >180 days; switchers, initiated new bDMARD. Concomitant conventional synthetic DMARD use, co-morbid chronic illnesses, and RA severity were assessed. All-cause/RA-related HCRU and costs were evaluated 12 months post-index.

RESULTS

Of 9567 identified patients, 67.2%, 17.3%, and 15.4% were continuers, discontinuers, and switchers, respectively. Switchers had the highest 12-month unadjusted mean all-cause costs of $34,585 vs $33,051 for continuers (p = 0.1158) and $24,915 for discontinuers (p < 0.0001; discontinuers vs continuers, p < 0.0001). RA-related costs comprised 82.8%, 31.4%, and 85.7% of total costs for continuers, discontinuers, and switchers, respectively. Of 764 switchers, 68.2% switched to alternative TNFi (cyclers), the rest to non-TNFi bDMARDs; 36.7% of patients who switched to TNFi switched again (to third-line bDMARD) vs 27.6% (p = 0.0313) of those who switched to non-TNFi bDMARDs. Switchers to non-TNFi bDMARDs had higher mean 12-month all-cause costs of $76,580 compared with $50,689 for switchers to alternative TNFi (p < 0.0001); biologic-administration visits comprised 78.8% of the greater total RA-related costs of switchers to non-TNFi bDMARDs.

CONCLUSIONS

Real-world TNFi discontinuation/switching rates correspond to randomized controlled trial non-response rates. TNFi cycling is common and associated with an increased likelihood of switching to third-line bDMARD. Switching to non-TNFi bDMARDs was associated with higher costs, mostly attributed to in-office administrations.

SU-E-T-190: Design, Development, and Evaluation of a Modified, Anthropomorphic, Head, Quality Assurance Phantom for Use in Stereotactic Radiosurgery

PURPOSE

To develop and evaluate a modified anthropomorphic head phantom for evaluation of stereotactic radiosurgery (SRS) dose planning and delivery.

METHODS

A phantom was constructed from a water equivalent, plastic, head-shaped shell. The original phantom design, with only a spherical target, was modified to include a nonspherical target (pituitary) and an adjacent organ at risk (OAR) (optic chiasm), within 2 mm, simulating the anatomy encountered when treating acromegaly. The target and OAR spatial proximity provided a more realistic treatment planning and dose delivery exercise. A separate dosimetry insert contained two TLD for absolute dosimetry and radiochromic film, in the sagittal and coronal planes, for relative dosimetry. The prescription was 25Gy to 90% of the GTV with >= 10% of the OAR volume receiving >= 8Gy. The modified phantom was used to test the rigor of the treatment planning process, dosimeter reproducibility, and measured dose delivery agreement with calculated doses using a Gamma Knife, CyberKnife, and linear accelerator based radiosurgery systems.

RESULTS

TLD results from multiple irradiations using either a CyberKnife or Gamma Knife agreed with the calculated target dose to within 4.7% with a maximum coefficient of variation of+/-2.0%. Gamma analysis in the coronal and sagittal film planes showed an average passing rate of 99.3% and 99.5% using +/-5%/3mm criteria, respectively. A treatment plan for linac delivery was developed meeting the prescription guidelines. Dosimeter reproducibility and dose delivery agreement for the linac is expected to have results similar to the results observed with the CyberKnife and Gamma Knife.

CONCLUSIONS

A modified anatomically realistic SRS phantom was developed that provided a realistic clinical planning and delivery challenge that can be used to credential institutions wanting to participate in NCI funded clinical trials. Work supported by PHS CA010953, CA081647, CA21661 awarded by NCI. DHHS.

Continuous versus intermittent stochastic resonance whole body vibration and its effect on pelvic floor muscle activity

AIMS

To determine the optimal stochastic whole body vibration (SR-WBV) load modality regarding pelvic floor muscle (PFM) activity in order to complete the SR-WBV training methodology for future PFM training with SR-WBV.

METHODS

The continuous and the intermittent SR-WBV modalities were tested by means of electromyography in two independent groups (27 women 8 weeks to 1-year postpartum and 23 women nulliparae or >1-year postpartum) with self-reported stress urinary incontinence. The change in the PFM activity within a single set and over three sets were calculated for both SR-WBV modalities together (time effect) and for both SR-WBV modalities separately (modality-time interaction).

RESULTS

There was no statistically significant or clinically relevant change in PFM activity over time or PFM fatigue in either SR-WBV modality within one or three sets and no difference between the modalities or the groups.

CONCLUSIONS

The lack of change in PFM activity could be due to a no more than moderate to submaximal PFM activity during SR-WBV, the maintenance of reflexive PFM activity despite PFM fatigue or a compensation of slow red PFM fiber fatigue by an increase of innervation frequency and motor unit recruitment of the fast white fibers. As there is no SR-WBV modality dependent difference regarding PFM activity, the continuous modality is recommended in clinical practice as it is easier to apply and less time consuming.

Continuous apple consumption induces oral tolerance in birch-pollen-associated apple allergy

BACKGROUND

Patients with birch pollen allergy (major allergen: Bet v 1) have often an associated oral allergy syndrome (OAS) to apple, which contains the cross-reactive allergen Mal d 1. As successful birch pollen immunotherapy does not consistently improve apple related OAS symptoms, we evaluated whether regular apple consumption has an effect on OAS and immune parameters of Mal d 1 or Bet v 1 allergy.

METHODS

A total of 40 patients with a clear history of birch pollen rhinoconjunctivitis and associated OAS to apple were included in an open, randomized, controlled clinical trial: 27 patients consumed daily defined amount of apple (1-128 g), doubling the amount every two to three weeks, while 13 patients remained untreated. Primary endpoint was the proportion of patients that achieved tolerance to at least 128 g of apple at the end of the study after 8 months. Exploratory endpoints were questionnaire about cross-reactive food and pollen allergy symptoms, conjunctival provocation test with birch pollen and Bet v 1, and in vitro tests (tIgE, sIgE, and IgG4 to Mal d 1 and Bet v 1; basophil activation test with both allergens).

RESULTS

Seventeen of 27 patients in active group and none of 13 patients in control group (P = 0.0001) could tolerate a whole apple after the intervention. However, differences in endpoints reflecting systemic immune reactivity did not reach statistical significance.

CONCLUSION

In patients with OAS to apple, tolerance can be safely induced with slowly, gradually increasing consumption of apple. However, the observation of a relapse after discounting of apple consumption and absence of immunologic changes suggest that induced tolerance is only transient.

Biosynthesis of sphinganine-analog mycotoxins

Sphinganine-analog mycotoxins (SAMT) are polyketide-derived natural products produced by a number of plant pathogenic fungi and are among the most economically important mycotoxins. The toxins are structurally similar to sphinganine, a key intermediate in the biosynthesis of ceramides and sphingolipids, and competitive inhibitors for ceramide synthase. The inhibition of ceramide and sphingolipid biosynthesis is associated with several fatal diseases in domestic animals and esophageal cancer and neural tube defects in humans. SAMT contains a highly reduced, acyclic polyketide carbon backbone, which is assembled by a single module polyketide synthase. The biosynthesis of SAMT involves a unique polyketide chain-releasing mechanism, in which a pyridoxal 5'-phosphate-dependent enzyme catalyzes the termination, offloading and elongation of the polyketide chain. This leads to the introduction of a new carbon-carbon bond and an amino group to the polyketide chain. The mechanism is fundamentally different from the thioesterase/cyclase-catalyzed polyketide chain releasing found in bacterial and other fungal polyketide biosynthesis. Genetic data suggest that the ketosynthase domain of the polyketide synthase and the chain-releasing enzyme are important for controlling the final product structure. In addition, several post-polyketide modifications have to take place before SAMT become mature toxins.

Confirmed Datura poisoning in a horse most probably due to D. ferox in contaminated tef hay

Two out of a group of 23 mares exposed to tef hay contaminated with Datura ferox (and possibly D. stramonium) developed colic. The 1st animal was unresponsive to conservative treatment, underwent surgery for severe intestinal atony and had to be euthanased. The 2nd was less seriously affected, responded well to analgesics and made an uneventful recovery. This horse exhibited marked mydriasis on the first 2 days of being poisoned and showed protracted, milder mydriasis for a further 7 days. Scopolamine was chemically confirmed in urine from this horse for 3 days following the colic attack, while atropine could just be detected for 2 days. Scopolamine was also the main tropane alkaloid found in the contaminating plant material, confirming that this had most probably been a case of D. ferox poisoning. Although Datura intoxication of horses from contaminated hay was suspected previously, this is the 1st case where the intoxication could be confirmed by urine analysis for tropane alkaloids. Extraction and detection methods for atropine and scopolamine in urine are described employing enzymatic hydrolysis followed by liquid-liquid extraction and liquid chromatography tandem mass spectrometry (LC/MS/MS).

Datura contamination of hay as the suspected cause of an extensive outbreak of impaction colic in horses : clinical communication

atura poisoning of horses is extensively reviewed. An outbreak of intractable impaction colic affecting 18 of 83 horses was stopped by withdrawing dried tef hay contaminated with young Datura plants. The dried, botanically identified Datura stramonium and D. ferox contained respectively 0.15 % mass/mass (m/m) hyoscyamine as well as 0.16 % m/m hyoscine (scopolamine) and only hyoscine at a concentration of 0.11 % m/m. Immature, unidentifiable plants resembling D. stramonium, contained 0.14 % m/m and 0.12 % m/m of the 2 respective tropane alkaloids. The outbreak was characterised by protracted and repeated colic attacks due to impaction of the large colon and/or caecum without any other anti-muscarinic signs. Comparative analyses of single specimens of dried seed of the 2 species collected from both fertilised and waste areas revealed that young South African Datura spp. had levels of tropane alkaloids comparable to those in the well-known toxic seed and were, consequently, equally toxic. The inherent danger of tef hay being contaminated with Datura is emphasised. To our knowledge this is the 1st field case of poisoning in horses ascribed to the vegetative parts of Datura spp.

The use of the standard exercise test to establish the clinical significance of mild echocardiographic changes in a Thoroughbred poor performer

A 4-year-old Thoroughbred gelding racehorse was referred to the Onderstepoort Veterinary Academic Hospital (OVAH) with a history of post-race distress and collapse. In the absence of any obvious abnormalities in the preceding diagnostic work-up, a standard exercise test was performed to determine an underlying cause for the post-race distress reported. In this particular case oxygen desaturation became evident at speeds as slow as 6 m/s, where PO2 was measured at 82.3 mm Hg. Similarly at a blood pH of 7.28, PCO2 had dropped to 30.0 mm Hg indicating a combined metabolic acidosis and respiratory alkalosis. The cause of the distress was attributed to a severe hypoxia, with an associated hypocapnoea, confirmed on blood gas analyses, where PO2 levels obtained were as low as 56.6 mm Hg with a mean PCO2 level of 25.4 mm Hg during strenuous exercise. Arterial oxygenation returned to normal immediately after cessation of exercise to 106.44 mm Hg, while the hypocapnoeic alkalosis, PCO2 25.67 mm Hg, persisted until the animal's breathing normalized. The results obtained were indicative of a dynamic cardiac insufficiency present during exercise. The combination of an aortic stenosis and a mitral valve insufficiency may have resulted in a condition similar to that described as high-altitude pulmonary oedema, with respiratory changes and compensation as for acute altitude disease. The results obtained were indicative of a dynamic cardiac insufficiency present during exercise and substantiate the fact that an extensive diagnostic regime may be required to establish a cause for poor performance and that the standard exercise test remains an integral part of this work-up.

[Rare seminoma metastasis to the corpus spongiosum and urethra]

Anaplastic seminomas account for 5-10% of all seminomas. Their metastatic pattern is similar to the classic form of seminoma. We report on an oligophrenic patient with seminoma pT1 who developed a metastasis to the corpus spongiosum and penile urethra, which was successfully treated by local external radiotherapy resulting in long-term tumor remission over a 4-year follow-up period.

Raised saturated-fat intake worsens vascular function in virgin and pregnant offspring of streptozotocin-diabetic rats

Adult offspring of severely diabetic pregnant rats are insulin resistant and display cardiovascular dysfunction. When pregnant they develop mild hyperglycaemia. Diets high in saturated fat have been implicated in the development of cardiovascular disease and vascular dysfunction. In the present study we have determined vascular function in small mesenteric arteries from offspring of normal (OC) and diabetic (OD) rats fed standard chow and offspring of diabetic rats fed a diet high in saturated fats (OD-HF) from weaning to adulthood, and throughout their subsequent pregnancies. OD rats displayed an increased sensitivity to noradrenaline (P < 0.05) and impaired sensitivity to the endothelium-dependent vasodilator, acetylcholine. The component of acetylcholine-induced relaxation attributable to endothelium-derived hyperpolarizing factor was reduced in OD-HF rats. Pregnant OD rats also demonstrated impaired maximum relaxation to acetylcholine (pregnant OD rats v. pregnant OC rats P < 0.05). In pregnant OD-HF rats noradrenaline sensitivity was enhanced and endothelium-dependent relaxation further reduced (pregnant OD-HF rats v. pregnant OC rats P < 0.001). The isoprostane, 8-epi-prostaglandin F2alpha, a marker of oxidative stress, was increased in pregnant OD rats (pregnant OD rats v. pregnant OC rats P

[Prolonged peridural analgesia (PDA) for postoperative pain therapy after major urologic interventions. Experiences with 172 adult patients]

The benefits of epidural analgesia are well known, but it is not well understood which types of urologic surgery benefit most from epidural analgesia. In this study, the effects and side effects of prolonged epidural analgesia are prospectively examined and analysed on 172 adult patients in three different operation groups. An epidural infusion of local anaesthetic combined with an opioid and adrenaline was given for a period of 5-7 days. There was no difference between the groups with respect to the effectiveness of the analgesia and patients' perception of the treatment. Mobilization differed, as expected, between the groups, however even after the most major surgery (e. g. cystectomy with bladder substitution), mobilization was impressively unproblematic. Retarded return of regular intestinal function after the transperitoneal operation and partly after lumbotomy compared with the extraperitoneal operation depended on which operation was performed and the amount of analgesia given. The side effects such as sedation, nausea and pruritus were conditional partly on the opiate and partly on the intervention. Up to 11 % showed slight muscular weakness of the lower limbs as a specific side effect of the local anaesthetic.

COMPLICATIONS

One patient died of cerebral hypoxia due to an initially undetected subdural catheter placement complicated by severe pre-existent carotid stenosis. In four patients, the epidural analgesia had to be stopped because of catheter migration. There was no clinical evidence of hematoma, abscess or permanent neurological damage. Epidural analgesia works well in terms of analgesia, mobilization and patient satisfaction, bearing in mind the potential side effects and complications. It can be recommended for lumbotomy and long transperitoneal operations however not for extraperitoneal interventions in the lower abdomen such as radical prostatectomy.

Growth factor receptors are differentially expressed in cancers of the papilla of vater and pancreas

OBJECTIVE

To compare growth factor receptor expression in papilla of Vater cancer and pancreatic cancer.

SUMMARY BACKGROUND DATA

Cancer of the papilla of Vater has a much better prognosis than pancreatic cancer. Earlier symptoms may result in earlier diagnosis, but different biologic growth behaviors and genetic alterations might also be explanations.

PATIENTS AND METHODS

Surgical specimens from papilla of Vater cancers (24 patients) and pancreatic cancers (80 patients), normal papilla of Vater tissues (20 patients), and normal pancreatic tissues (24 patients) were frozen and fixed. The authors compared the expression of the epidermal growth factor receptor (EGFR) and c-erbB2 and c-erbB3 by Northern blot, in situ hybridization, and immunohistochemistry.

RESULTS

In papilla of Vater cancer, Northern blots showed comparable EGFR and c-erbB2 mRNA expression but significantly lower c-erbB3 mRNA levels than in normal papilla. In pancreatic cancer, mRNA expression was enhanced compared with normal controls for EGFR (4-fold), c-erbB2 (2.5-fold), and c-erbB3 (5.2-fold). In situ hybridization confirmed this and showed mRNA expression only in cancer cells. EGFR immunohistochemical staining scores were comparable in papilla of Vater cancer (1.17 +/- 0.22) and normal papilla (1.42 +/- 0.25). Staining scores for c-erbB2 (2.72 +/- 0.40 vs. 3.89 +/- 0.37) and c-erbB3 (2.78 +/- 0.35 vs. 3.89 +/- 0.53) were slightly lower than controls in papilla of Vater cancer. In pancreatic cancer, immunostaining scores for EGFR, c-erbB2, and c-erbB3 were significantly higher than controls.

CONCLUSION

Members of the EGFR family show similar or lower expression in papilla of Vater cancer than in normal controls. In pancreatic cancer, these receptors are upregulated. This supports the hypothesis that papilla of Vater cancer and pancreatic cancer have biologic differences that may contribute to the different growth of these tumors.

Understanding technology in contemporary surgical nursing: a phenomenographic examination

The purpose of this paper is to describe the result of phenomenographic research undertaken to identify the qualitatively different ways technology is understood and experienced by contemporary surgical nurses. Twenty surgical nurses were interviewed and conversations were recorded through the use of drawings and audiotape that were analysed using a series of seven analytical steps. There were two major outcomes of the research: eight categories of description were revealed and each one constitutes a conception of the experience and understanding of technology, and an outcome space portraying the logical relations between conceptions was identified. Conceptions revealed demonstrate the importance of technology to the theory, practice, research and education of nurses, and highlight the complexity and significance of technology in contemporary surgical nursing experience.

Phenomenography: a qualitative research approach for exploring understanding in health care

Phenomenography is a little-known qualitative research approach that has potential for health care research, particularly when people's understanding of their experience is the goal. Phenomenography is explained as a qualitative, nondualistic research approach that identifies and retains the discourse of research participants. This article seeks to present the major assumptions associated with phenomenographic research. An example of the way in which research outcomes are presented is included to emphasize its distinctiveness. It is noted that phenomenography has potential in the area of qualitative health research and will benefit from ongoing development and application.

Maternal food restriction in the second half of pregnancy affects vascular function but not blood pressure of rat female offspring

Food restriction during pregnancy in rats induces intrauterine growth retardation with consequences persisting into adulthood. In the present study we have investigated the hypothesis that malnutrition in pregnant rats may lead to altered cardiovascular function in adult female offspring. Perinatal growth retardation was induced by a 50% reduction of normal dietary intake in rats during the second half of pregnancy. Systolic and diastolic blood pressure values and heart rate were recorded in conscious female offspring (100 d old) using a femoral artery probe. No significant differences in heart rate, or in systolic and diastolic blood pressures were recorded between control offspring and offspring of nutritionally deprived rats. In order to ascertain whether cardiovascular variables in the offspring were influenced by lactation, subgroups of offspring from food-restricted dams were fostered with lactating dams fed on a normal diet. Blood pressure and heart rate were also found to be normal in these offspring. The rise in blood pressure associated with NO inhibition was similar in all groups. Isolated resistance artery function was assessed in vitro in offspring (100-120 d old) of a second group of semi-starved dams. Small mesenteric arteries from these animals showed reduced endothelium-dependent relaxation (to acetylcholine and bradykinin), but enhanced sensitivity to exogenous NO (sodium nitroprusside). We conclude that food restriction during the second half of pregnancy and/or lactation does not induce hypertension in adult offspring, but may effect subtle changes in vascular function.

Multiple machine implementation of enhanced dynamic wedge

PURPOSE

After acquiring 4 years of experience with Dynamic Wedge, a software-driven one-dimensional (1D) compensation system, we implemented a new software version called Enhanced Dynamic Wedge (EDW). The EDW allows larger (30 cm) and asymmetric field sizes and additional angles for wedged fields. We implemented this software on four similar dual-energy accelerators that also possess upper and lower physical wedge sets. Our goal was to implement EDW with one common wedge factor (WF) table and one set of treatment-planning files.

METHODS AND MATERIALS

We measured WFs with an ionization chamber and isodose profiles with both film and a diode array. We used a calculation scheme that requires only entry of the wedge angle and fixed jaw value. Filters for computerized treatment planning were configured for each wedge angle. We also examined to what degree the multileaf collimation (MLC) orientation, which is orthogonal to the EDW direction, was compromised for specific treatment sites. As a comparative test, we examined the dosimetric consistency for the 8 sets of physical wedges on the four machines. Finally, we updated our DW quality assurance program for EDW.

RESULTS

The measured EDW WF was common for all four machines to within +/- 1.5% and the calculation scheme held to within 1.5%. The EDW isodoses were consistent among the machines as measured by film and diode array. The treatment-planning filters provided computed isodose profiles that were nearly identical to measured profiles. Regarding MLC orientation, we found that the collimator angle needed for EDW did not compromise isodose distributions, as apparent in measured isodoses and calculated dose-volume histograms. The consistency of the physical wedges did not fare as well. Two of the lower wedge sets had Wfs and profiles different (> 3%) from the other wedge sets.

CONCLUSIONS

We have successfully implemented EDW on four machines using only one WF table and one set of treatment-planning filters. The EDW provides for improved treatment techniques for particular sites due to the large field sizes and additional angles available. Daily treatment efficiency has increased because of the remote capability provided by EDW.

Physician resource utilization in radiation oncology: a model based on management of carcinoma of the prostate

PURPOSE

To develop a methodology to estimate the comparative cost of physician time in treating patients with localized prostate cancer, using as an example two-dimensional (2D) vs. three-dimensional (3D) conformal irradiation techniques, and to illustrate how current cost-accounting techniques can be used to quantify the cost of physician time and effort of any treatment.

METHODS AND MATERIALS

Activity-based costing, a recent innovation in accounting, widely recommended for estimating and managing the costs of specific activities, was used to derive physician resource utilization costs (actual cost of the physician services and related support services consumed).

RESULTS

Patients treated with 3D conformal irradiation consume about 50% more physician time than patients receiving 2D conventional radiation therapy. The average professional reimbursement for the 3D conformal irradiation is only about 26% more than for the 2D treatment. Substantial variations in cost are found depending on the total available physician working hours. In an academic institution, a physician working 40 hours a week would have to spend an average of about 60% of available time on clinical services to break even on a 2D treatment process and over 74% of available time on clinical work to break even on a 3D treatment process. The same physician working 50 hours a week would have to spend an average of about 48% of available time on 2D clinical services and about 60% of available time on 3D clinical work to break even. Current Medicare reimbursement for 3D treatment falls short of actual costs, even if physicians work 100% of a 50-hour week. Medicare reimbursement for 2D barely allows the department to break even for 2D treatments.

CONCLUSIONS

Costs based on estimates of resource use can be substantially under- or overestimated. A consistent language (method) is needed to obtain and describe the costs of radiation therapy. The methodology described here can help practitioners and researchers more accurately interpret actual cost information. Future use of such cost-estimation methodologies could provide consistent and comparable costs for negotiations with health care providers and help assess different treatment strategies.

[Treatment of bacterial osteomyelitis using ultrasonic energy waves]

The method and results of uncommon ultrasound treatment in 82 cases of osteomyelitis are presented. The method was supplemented with intraoperative Th 99m isotope diagnostics as well as fluorescence based diagnosis to identify necrotic bone fragments. Ultrasound energy had advantageous effect on soft tissue healing and osteogenesis.

[Percutaneous resection of osteoid osteoma]

Therapeutic management of osteoid osteomas may vary from conservative medical treatment to more aggressive, though effective, surgery. Based on observations in 4 cases in children, we demonstrate the importance of localizing the lesion on the CT-scan before percutaneous resection of the osteoid osteoma involving small bones since this method is the most conservative surgical procedure.

Three-dimensional treatment planning and conformal radiation therapy: preliminary evaluation

Preliminary clinical results are presented for 209 patients with cancer who had treatment planned on our three-dimensional radiation treatment planning (3-D RTP) system and were treated with external beam conformal radiation therapy. Average times (min) for CT volumetric simulation were: 74 without or 84 with contrast material; 36 for contouring of tumor/target volume and 44 for normal anatomy; 78 for treatment planning; 53 for plan evaluation/optimization; and 58 for verification simulation. Average time of daily treatment sessions with 3-D conformal therapy or standard techniques was comparable for brain, head and neck, thoracic, and hepatobiliary tumors (11.8-14 min and 11.5-12.1, respectively). For prostate cancer patients treated with 3-D conformal technique and Cerrobend blocks, mean treatment time was 19 min; with multileaf collimation it was 14 min and with bilateral arc rotation, 9.8 min. Acute toxicity was comparable to or lower than with standard techniques. Sophisticated 3-D RTP and conformal irradiation can be performed in a significant number of patients at a reasonable cost. Further efforts, including dose-escalation studies, are necessary to develop more versatile and efficient 3-D RTP systems and to enhance the cost benefit of this technology in treatment of patients with cancer.