Single-incision laparoscopic reversal of Hartmann's operation through the stoma site: comparative outcomes with conventional laparoscopic and open surgery

AIM

Restoration of bowel continuity after Hartmann's procedure (RoH) can be challenging and associated with considerable morbidity. A technique using single-incision laparoscopic surgery through the stoma site (SIL RoH) has been shown to be feasible and safe. In this study, we compared clinical outcomes of SIL RoH with conventional laparoscopic surgery (CL) and open surgery (OS).

METHODS

This was a retrospective analysis of a prospectively maintained database between 2007 and 2017 in a UK colorectal unit. The access technique was decided by the surgeon on a case by case basis.

RESULTS

A total of 106 patients underwent RoH. It was carried out for diverticular disease (n = 71, 67.6%), cancer (n = 19, 17.9%) and anastomotic leak (n = 4, 3.8%). The remainder (n = 12, 11.3%) were for miscellaneous reasons including trauma. Most RoHs were performed via OS (n = 87, 81.1%). The most common intended approaches for RoH were SIL (n = 56, 52.8%) and OS (n = 34, 32.1%) with fewer starting with CL (n = 16, 15.1%). Conversion to OS took place in five (8.9%) patients with SIL and six (37.5%) with CL (P = 0.005). Postoperative complications occurred in 17 (30.4%) for SIL, seven (43.8%) for CL and 17 (50.0%) for OS (P = 0.162). Median operating time for SIL was 146 min (range 44-389), 211 min (109-320) for CL and 211 min (85-420) for OS (P < 0.001). Median length of stay was 4 days (2-44) for SIL compared to 6 (3-34) for CL and 7 (4-34) for OS (P < 0.001). Discharge on or before day 5 was achieved in 41 (74.5%) patients for SIL compared to six (37.5%) for CL and seven (20.6%) for OS (P < 0.001).

CONCLUSION

Compared to OS and CL, SIL RoH appears to have shorter operating times and hospitalization, with no discernible difference in morbidity; this finding requires further evaluation in a randomized setting.

Clinical outcomes and inflammatory response to single-incision laparoscopic (SIL) colorectal surgery: a single-blinded randomized controlled pilot study

AIM

Single-incision laparoscopic (SIL) surgery is expanding, but its benefits, efficacy and safety compared with conventional laparoscopic (CL) surgery remain unclear. This pilot study examined clinical outcomes and biochemical markers of inflammation for colorectal resections by SIL and CL in a randomized controlled pilot trial.

METHOD

Fifty patients undergoing elective colorectal resection were randomized to either SIL or CL. Primary outcomes were operating time and length of stay (LoS); secondary outcomes included combined length of scars, pain scores, complications, Quality of Life EQ5D-VAS and the inflammatory markers interleukin-6 (IL-6), IL-8 and C-reactive protein (CRP) at baseline, 2, 6, 24 and 72 h.

RESULTS

There was no difference in age, gender, body mass index, indications and site of surgery, American Society of Anesthesiologists grade or incidence of previous surgery between the groups. Except for one conversion from SIL to open surgery, surgery was completed as intended. No difference between SIL and CL was found for operating time [median 130 (72-220) vs 130 (90-317) min, respectively, P = 0.528], LoS [median 4 (3-8) vs 4 (2-19)days, P = 0.888] and time to first flatus [2 (1-4) vs 2 (1-5) days, P = 0.374]. The combined length of scars was significantly shorter for SIL [4 (2-18) vs 7 (5-8) cm, P < 0.001]; in each group, four postoperative complications occurred (16%). Postoperative pain scores were similar [mean 7.67 (interquartile range 4) vs 7.25 (interquartile range 3.75), P = 0.835] to day 3. EQ5D-VAS was no different for both groups at discharge [72.5 (40-90) vs 70 (30-100), P = 0.673] but slightly higher for CL at 3 months [79 (45-100) vs 90 (50-100), P = 0.033].The IL-6, IL-8 and CRP levels between both groups showed similar peaks and no significant differences.

CONCLUSION

SIL colorectal surgery by experienced laparoscopic surgeons appears to be safe and equivalent to CL, with no discernible difference in its effect on the physiological response to surgical trauma.

The NHS Bowel cancer screening programme achieves the anticipated survival improvement, but participation must be improved

Purpose The NHS Bowel cancer screening programme (NHSBCSP) aims to reduce colorectal cancer (CRC) cumulative mortality by up to 23 per cent; long-term outcomes at national level are not yet known. The purpose of this paper is to examine a local population of CRC patients of screening age for their characteristics and long-term survival in relation to their presentation, including through the NHSBCSP. Design/methodology/approach Retrospective analysis of a prospectively maintained CRC database for the years 2009-2014 in a single district hospital providing bowel cancer screening and tertiary rectal cancer services. Findings Of 528 CRC patients diagnosed in the screening age range, 144(27.3 per cent) presented through NHSBCSP, 308(58.3 per cent) electively with symptoms and 76(14.4 per cent) as emergency. NHSBCSP-diagnosed patients were younger (median 66 vs 68 and 69 years, respectively, p=0.001), had more often left-sided cancers (59(41.0 per cent) vs 82(26.6 per cent) and 24(31.6 per cent), respectively, p=0.001), more UICC-stage I (42(29.2 per cent) vs 49(15.9 per cent) and 2(2.6 per cent)), stage III (59(41.0 per cent) vs 106(34.4 per cent) and 20(26.3 per cent)) and less stage IV disease (8(5.6 per cent) vs 61(19.8 per cent) and 34 (44.7 per cent), respectively, p<0.001). Three-year overall survival was best for NHSBCSP and worst for emergency patients (87.5 per cent vs 69.0 per cent and 35.3 per cent, respectively, LogRank p<0.001). Originality/value Patients diagnosed within the NHSBCSP have improved outcome compared to both symptomatic elective and emergency presentations. A reduction in overall cumulative mortality in order of 25 per cent may well be achieved, but continuing high levels of emergency presentations and undetected right-sided disease emphasise need for further improvement in public participation in the NHSBCSP and research into more sensitive and acceptable alternative screening methods.

Volume-outcome relationship for colorectal cancer in primary care: a prospective cohort study

Purpose Higher caseloads are associated with better outcomes for many conditions treated in secondary and tertiary care settings, including colorectal cancer (CRC). There is little known whether such volume-outcome relationship exist in primary care settings. The purpose of this paper is to examine general practitioner (GP) CRC-specific caseload for possible associations with referral pathways, disease stage and CRC patients' overall survival. Design/methodology/approach The paper retrospectively analyses a prospectively maintained CRC database for 2009-2014 in a single district hospital providing bowel cancer screening and tertiary rectal cancer services. Findings Of 1,145 CRC patients, 937 (81.8 per cent) were diagnosed as symptomatic cancers. In total, 210 GPs from 44 practices were stratified according to their CRC caseload over the study period into low volume (LV, 1-4); medium volume (MV, 5-7); and high volume (HV, 8-21 cases). Emergency presentation (LV: 49/287 (17.1 per cent); MV: 75/264 (28.4 per cent); HV: 105/386 (27.2 per cent); p=0.007) and advanced disease at presentation (LV: 84/287 (29.3 per cent); MV: 94/264 (35.6 per cent); HV: 144/386 (37.3 per cent); p=0.034) was more common amongst HV GPs. Three-year mortality risk was significantly higher for HV GPs (MV: (hazard ratio) HR 1.185 (confidence interval=0.897-1.566), p=0.231, and HV: HR 1.366 (CI=1.061-1.759), p=0.016), but adjustment for emergency presentation and advanced disease largely accounted for this difference. There was some evidence that HV GPs used elective cancer pathways less frequently (LV: 166/287 (57.8 per cent); MV: 130/264 (49.2 per cent); HV: 182/386 (47.2 per cent); p=0.007) and more selectively (CRC/referrals: LV: 166/2,743 (6.1 per cent); MV: 130/2,321 (5.6 per cent); HV: 182/2,508 (7.3 per cent); p=0.048). Originality/value Higher GP CRC caseload in primary care may be associated with advanced disease and poorer survival; more work is required to determine the reasons and to develop targeted intervention at local level to improve elective referral rates.

Primary care referral practice, variability and socio-economic deprivation in colorectal cancer

AIM

The reasons for pre-hospital delay of the diagnosis of cancer are multifactorial, but include a physician-related component. Urgent cancer pathways and direct-to-test approaches have been implemented, but the emergency presentation of colorectal cancer (CRC) remains little changed over recent years. We examined the variability between primary care providers in referral patterns and its effect on outcome.

METHOD

A retrospective analysis was performed of a prospectively maintained database for 2009-2014 in a UK district hospital providing bowel cancer screening and tertiary rectal cancer services.

RESULTS

Of 1145 CRC patients, 937 (81.8%) were diagnosed with a symptomatic cancer; 229/937 (24.4%) initially presented as an emergency. Between 44 primary care providers, emergency presentation varied between 8.3% and 57.1%. Patients of providers with high levels of emergency presentations (HV) had more advanced cancers than those of providers with medium (MV) or low levels (LV) [103/253 (40.7%), 154/461 (33.4%), 65/223 (29.1%); P = 0.025] and a lower 3-year overall survival (50.2%, 57.8%, 65.6%; P = 0.013), but with no difference in case-mix or deprivation levels. In adjusted analysis, this difference remained significant (advanced disease, OR 1.663, P = 0.011; 3-year hazard ratio 1.479, P = 0.010; comparing HV with LV). Conversely, elective suspected cancer referrals were less often used amongst diagnosed cancers [LV 136/223 (61.0%), MV 228/461 (49.5%), HV 114/253 (45.1%), P < 0.001] with limited evidence for a more selective approach in the use of the 2-week rule amongst all 2-week rule referrals [LV 136/2508 (5.4%); MV 228/4239 (5.4%); HV 115/1526 (7.8%); positive cancer diagnosis, P = 0.005].

CONCLUSION

Significant variability in emergency presentation of CRC requires local audit and examination of the reasons for delay in diagnosis and targeted measures to improve performance in non-emergency referral pathways.

Transanal endoscopic microsurgery in the management of rectal wall endometriosis

A 29-year-old woman with known history of endometriosis was referred to colorectal outpatient clinic from gynaecology with a history of intermittent rectal bleeding and no associated bowel symptoms. Flexible sigmoidoscopy in concordance with pelvic MRI revealed a 3×2×2 cm sessile lesion in the anterior rectal wall. The lesion was also palpable as a firm mass on digital rectal examination. From the gynaecological point of view no intra-abdominal exploration was required; the sole rectal wall lesion was removed with the minimally invasive surgical technique of transanal endoscopic microsurgery. Full thickness rectal wall excision sample was reported to be histologically complete and confirmed endometriosis. No recurrence was detected at endoscopic follow-up at 6 months. The patient remained symptom free. Therefore, we demonstrated a case of minimally invasive removal of a rectal wall large endometriosis nodule in a fertile woman with a complete, symptomatic, uneventful recovery.

Single-incision laparoscopic (SIL) sigmoid colectomy and uterus-preserving repair for colo-uterine fistula secondary to severe diverticular disease: an unusual technical solution for an unusual presentation of a common disease

Colouterine fistula as a potential complication of chronic diverticulitis is a rare entity with less than 30 cases reported worldwide. Generally, patients require a multidisciplinary approach including a major laparotomy with hysterectomy and sigmoid colectomy, and, occasionally, temporary colostomy. We report the first attempt of a novel, minimally invasive technique for managing a case of benign colouterine fistula with single-incision laparoscopic (SIL) sigmoid colectomy and uterus preservation. A small, 3 cm incision site provided access for the whole operation, as well as played a role as the specimen extraction site. Malignant fistulas and large uterine defects may require hysterectomy, however, laparoscopic closure of uterine wall defects can be considered as a reasonable alternative in selected patients, avoiding the higher risks associated with hysterectomy and keeping fertility at younger ages. Single incision laparoscopy in complicated diverticular disease and fistula formation cases is a challenging but technically feasible option, in experienced hands.

Adipose Tissue-Derived Regenerative Cell-Enhanced Lipofilling for Treatment of Cryptoglandular Fistulae-in-Ano: The ALFA Technique

BACKGROUND

The treatment of complex fistulae-in-ano is challenging and often includes a number of operations due to high rates of recurrence. Recently, techniques using in vitro expanded adipose tissue-derived stem cells have been described. We describe a novel treatment for cryptoglandular fistulae used in 7 patients, using a combination of surgical closure of the internal opening and real-time autologous adipose tissue-derived regenerative cells (ADRC)-enhanced lipofilling, without need for in vitro expansion.

METHODS

Following exclusion of active perianal sepsis, patients underwent a standard tumescent liposuction procedure, harvesting ~300 to 400 mL of raw lipoaspirate. The lipoaspirate was prepared in real time, using the Celution 800/CRS system to obtain the stromal vascular fraction containing ADRCs. After excision of the fistula tract and closure of the internal orifice, fresh ADRC-enhanced lipoaspirate was injected into and around the fistula tract.

RESULTS

At 6-months' follow-up, 5 of 7 (71.4%) patients showed clinical signs of fistula closure; one of these patients had a recurrence at 10 months due to sepsis. The remaining 4 patients (57.1%) all had complete fistula closure at a median of 46 months' follow-up. There were no adverse events associated with the technique, and no new incontinence.

CONCLUSION

Treatment of cryptoglandular fistulae-in-ano with ADRC-enhanced lipofilling appears feasible and safe, and may add to the range of procedures that can be used to treat this difficult problem.

Intra-arterial methylene blue injection into ex vivo colorectal cancer specimens improves lymph node staging accuracy: a randomized controlled trial

AIM

A randomized controlled trial was carried out to study the effect of a recently proposed technique of ex vivo intra-arterial methylene blue injection of the surgical specimen removed for colorectal cancer on lymph node harvest and staging.

METHOD

Between May 2012 and February 2013, 100 consecutive colorectal cancer resection specimens in a single institution were randomly assigned to intervention (methylene blue injection) and control (standard manual palpation technique) groups before formalin fixation. The specimen was then examined by the histopathologist for lymph nodes.

RESULTS

Both groups were similar for age, sex, site of tumour, operation and tumour stage. In the intervention group, a higher number of nodes was found [median 23 (5-92) vs. 15 (5-37), P < 0.001], with only one specimen not achieving the recommended minimum standard of 12 nodes [1/50 (2%) vs. 8/50 (16%), P = 0.014]. However, there was no upstaging effect in the intervention group [23/50 (46.0%) vs. 20/50 (40.0%); P = 0.686]. With a significantly lower number of nodes harvested in rectal cancer, the positive effect of the intervention was particularly observed in the patients who underwent preoperative neoadjuvant radiotherapy [median 30 nodes (12-57) vs. 11 (7-15); P = 0.011; proportion of cases with < 12 nodes 0/5 vs. 5/8 (62.5%), P = 0.024].

CONCLUSION

Ex vivo intra-arterial methylene blue injection increases lymph node yield and can help to reduce the number of cases with a lower-than-recommended number of nodes, particularly in patients with rectal cancer having neoadjuvant treatment. The technique is easy to perform, cheap and saves time.

Autologous adipose-tissue derived regenerative cells for the treatment of complex cryptoglandular fistula-in-ano: a report of three cases

The treatment of complex fistulae-in-ano is challenging and often includes a number of operations due to high rates of recurrence. We report the successful treatment of three consecutive patients with long-standing cryptoglandular fistula-in-ano with a novel combination of mucosal advancement flap and adipose-tissue derived regenerative cells (ADRCs) from the stromal vascular fraction (SVF) obtained from a simple lipoaspiration procedure, using Celution technology. There was no operative morbidity; one patient who had a colostomy for faecal diversion has since undergone restoration of bowel continuity. All thee fistulae remain healed at 2-3-year follow-up. Lipofilling of cryptoglandular fistulae-in-ano with ADRC-enhanced lipofilling appears feasible and safe, and may add to the range of procedures that can be used to treat this difficult problem.

Laparoscopic proctocolectomy with restorative ileal-anal pouch

OBJECTIVE

The aim of the study was to analyse the outcome of restorative proctocolectomy carried out by laparoscopic surgery.

METHODS

A prospectively collected electronic database of all colorectal laparoscopic procedures performed between April 2001 and July 2003 has been used to identify surgical outcomes in 14 consecutive patients who have undergone laparoscopic RPC.

RESULTS

Fourteen patients (5 male), median BMI 24 kg/m(2) have undergone restorative laparoscopic proctocolectomy over a two year period: 13 (ulcerative colitis, one with cancer) and 1 (FAP). The median operation time was 260 min; time has not decreased with experience. There were no intra-operative surgical complications or deaths. Patient controlled analgesia continued for a median of 36 h. The median time to diet was 48 h and median hospital stay 7 days; three patients required nasogastric aspiration for delayed gastric emptying. Eighteen regional lymph nodes were retrieved local to the carcinoma. There was one anastomotic leak. All covering stomas were closed by 6 months (12 by eight weeks). All 14 patients are fully continent, able to suppress urgency and have a median pouch frequency of 4/24 h. None admit to having problems with potency, orgasm sensation, ejaculation, micturition. One lady reports dysparunia. All are highly satisfied with functional outcome and cosmesis.

CONCLUSION

We are encouraged to continue to offer our patients the option of a laparoscopic resection.

Management of recurrent anastomotic stricture and iatrogenic stenosis by circular stapler

Anastomotic stricture is an increasingly common clinical finding. It is thought to arise because of ischemia, disruption, or leakage at an anastomosis site. Its management can be difficult and strictures often are resistant to standard dilation therapy. Major corrective surgery is possible; however, it is technically challenging and not without risk. We have used a circular stapler to excise colorectal strictures, introducing the anvil of the stapler via a proximal stoma or colotomy, drawing the anvil through the stricture with a snare via a colonoscope and affixing it to the body of a circular staple gun and excising the stricture. We have with found this to be an effective treatment in appropriately selected patients.

Syndrome of primary ciliary dyskinesia: Kartagener's syndrome with empyema thoracis and azoospermia

Primary ciliary dyskinesia is a genetically determined disorder with several pulmonary complications. A case of an 18-year-old male suffering from this entity and having empyema thoracis and azoospermia is presented here.

Reliability of sequential naloxone challenge tests

To determine the reliability of serial naloxone challenges, five heroin addicts stabilized on methadone were given 0.2 mg naloxone intravenously on three consecutive days. Two-factor ANOVA revealed that the between-subjects effect accounted for at least 63% of the variance in each of the dependent measures, and the effect of challenge number for at most 22%. Withdrawal tended to be slightly more severe for the first challenge. Intraclass correlation coefficients were calculated for the area-under-the-curve of the change from baseline: subject-rated (.74) and observer-rated (.71) withdrawal, pulse (.88), systolic blood pressure (.58), diastolic blood pressure (.85), and skin temperature (.63).

Sulfate conjugates of catecholamines in the allantoic fluid of the chicken embryo

In addition to free dopamine (DA), norepinephrine (NE), and epinephrine (E), the allantoic fluid of the 13-day-old chicken embryo contains sulfate conjugates of these three catecholamines (CAs). The concentration of DA sulfate is relatively low, while NE and E sulfates occur at levels similar to those of the free fractions. The comparatively low concentration of free CAs in the amniotic fluid, seen in a previous study, is confirmed. However, the amniotic barrier for sulfated CAs is much stronger, possibly absolute. Though some technical difficulties remain to be resolved, the chicken embryo may become a useful model for the study of the prenatal functions of CA conjugates.

Stress-related changes in the hematological profile of the American eel (Anguilla rostrata)

The authors investigated the impact of environmentally realistic concentrations of cadmium (Cd) on the hematological responses of the eel to acute stress. After 8 weeks of exposure to 150 micrograms Cd/liter, there was a significant reduction in the total erythrocyte count, hemoglobin (Hb), and hematocrit (Hct). Total leukocyte counts, leukocrit, and large lymphocytes were significantly increased, while the proportion of small lymphocytes fell. After 8 weeks of Cd exposure, acute stress was induced by a 2-min exposure to CO2 bubbles. The untreated control fish responded strongly by erythrocyte swelling, which was evident from a marked increase in the Hct and mean cellular volume, and a decreased mean cellular hemoglobin concentration. Furthermore, there was a marked granulocytosis and a strong drop in the thrombocyte count. After Cd treatment, the erythrocyte changes were attenuated and shorter, granulocytes were increased, and there was no drop in the thrombocyte count. It appears that the Cd exposure decreased the erythrocyte response to adrenergic stress signals. It also decreased the stress-related granulocytosis, and it prevented the drop of the thrombocyte count.

Response of plasma cortisol to environmental cadmium in the eel, Anguilla rostrata LeSueur

1. Long-term exposure (16 weeks) of the American eel, Anguilla rostrata, to an environmentally realistic concentration of cadmium (150 micrograms/l) causes a chronic elevation of plasma cortisol. During this time span, the eels retain the ability to respond to a weak additional stress (CO2 bubbles for 1 min) with a further increase in plasma cortisol. 2. Plasma glucose levels are significantly lowered after two weeks of exposure to cadmium (75 and 150 micrograms/l). However, subsequently they return close to control levels. 3. It is concluded that (a) a moderate cadmium pollution of the eel's habitat suffices to cause chronic stimulation of the eel's adrenocortical axis, and (b) the resulting continued hypercortisolemia must seriously affect the eel's metabolism, immunosystem, gonadal maturation, and ability to migrate to its spawning grounds.

Trace metal (Cu and Zn) adaptation of organ systems of the american eel, Anguilla rostrata, to external concentrations of cadmium

1. The impact of external cadmium on the concentrations of cadmium (Cd), copper (Cu) and zinc (Zn) in seven tissues of the American eel, Anguilla rostrata was investigated. Even after a week in freshwater with undetectable levels of Cd, the tissues of eels caught in fresh and/or brackish waters of the United States east coast contained Cd in kidney, liver, gut, and brain. 2. When the eels were exposed up to 16 weeks to low and high sublethal concentrations of Cd (75 and 150 micrograms/l, respectively), the highest tissue concentrations of Cd were found after two weeks of exposure. The accumulation was dose-related in all tissues studied except for the kidney. After 8 weeks of Cd exposure, the tissue levels of Cd were markedly reduced, and they were in a similarly low range after 16 weeks. At this time, the highest Cd concentrations were found in the gills and kidney. 3. After two weeks of Cd exposure, there was a drop of the tissue concentrations of Cu in liver and heart, and of Zn in gut and liver. The low concentrations of the two metals in other organs did not allow an evaluation of the Cd impact. After 16 weeks, the Cu concentrations in all tissues, with the exception of the liver, were similar to, or even higher than control levels. At the same time, Zn concentrations exceeded the control levels in heart and kidney of eels exposed to 75 and 150 micrograms Cd/l, respectively. 4. It is clear that some tissues of the eel are able to maintain or restore normal levels of Cu and Zn, up to 16 weeks, despite concomitant Cd accumulation.

Impact of cadmium on the mummichog Fundulus heteroclitus and the role of calcium in suppressing heavy metal toxicity

1. Freshwater adapted mummichogs (Fundulus heteroclitus) were exposed to cadmium. In soft water (less than or equal to 5 mg/l CaCO3), the 4-day safe (TL100) and sublethal (TL50) tolerance limits (TLs) for cadmium were 0.14 microgram/l and 12.2 micrograms/l, respectively. 2. Survival declined with increasing cadmium concentration and the length of exposure. The toxicity of cadmium was reduced in water with high calcium concentration (200 mg/l CaCO3). Pre-exposure to calcium also prolonged the survival in cadmium-containing water. 3. The mummichog appears to be extremely well suited for monitoring environmental cadmium poisoning.

The avian allantois: a depot for stress-released catecholamines

Plasma and amniotic and allantoic fluid of 10- and 14-day-old chicken embryos contain free dopamine (DA), norepinephrine (NE), and epinephrine (E). Compared with postnatal chickens, concentrations of DA and E in the plasma are very high, and they are even higher in the allantoic fluid. In contrast, the allantoic concentration of NE is below the plasma level. In the amniotic fluid, the concentrations of all three catecholamines (CAs) are below the plasma levels. High concentrations of DA and E in the allantoic fluid after opening of the egg shell decline during the following 24 hr, which indicates that they are due to stress. Asphyxia, handling, disturbance of allantoic fluid, and cooling are also perceived as stress and are followed by immediate accumulation of CAs in the allantoic fluid. DA and E respond to stress in like manner, while NE often responds with an opposite trend. It appears that the avian allantois, in addition to its role in respiration and urea disposal, also serves the instant CA removal from the circulation. Both the amniotic and the allantoic membranes of the chicken should be ideal models for the study of CA transport mechanisms.

Individual and combined toxicity of common pesticides to teleost Puntius conchonius Hamilton

Individual and combined toxicity of three pesticides, endosulfan, phosphamidon, and aldicarb was evaluated in P. conchonius. The 48 hr LC50 was 21.36 and 446.5 ppm respectively for endosulfan and phosphamidon. When tested jointly, 48 hr LC50 for different ratios of these pesticides were 0.332 (IE:3P), 0.224 (IE:1P), and 0.178 ppm (3E:1P). The cotoxicity coefficients for these combinations were 1793, 3986, and 10009, respectively. An equitoxic mixture of endosulfan, phosphamidon, and aldicarb yielded a 48 hr LC50 of 130.5 ppm. An enhanced toxic impact is indicated when the pesticides are present together rather than as individual compounds.

In vivo and in vitro effects of cadmium on selected enzymes in different organs of the fish Barbus conchonius Ham. (rosy barb)

1. Enzyme modulation by cadmium in selected organs of the fish, Barbus conchonius (rosy barb), was investigated in vivo (48 hr exposure to 12.6 mg/l cadmium chloride) and in vitro (10(-6) M cadmium chloride). 2. The acetylcholinesterase (AchE) activity was depressed in the gills but stimulated in the skeletal muscles and brain in vivo. The hepatic, branchial, and renal acid phosphatase (AcP) activity decreased marginally in vivo but it was significantly increased in the gut and ovary. In vitro, except for the liver, the AcP activity was depressed in the selected organs. Collaterally, gut alkaline phosphatase (AlP) was significantly inhibited but a pronounced stimulation was noted in the kidneys and ovary in vivo. In vitro, the AlP activity was conspicuously elevated in the kidneys and gut, and moderately in the gills. 3. Cadmium inhibited the glutamate-oxaloacetate and glutamate-pyruvate transaminases (GOT and GPT) in the liver, gills and kidneys in vivo. In vitro, the GOT and GPT activities were decreased in the liver, gills and kidneys. The lactic dehydrogenase (LDH) was significantly stimulated by Cd in the heart in vivo but in vitro the metal inhibited the enzyme in the gills. 4. Enzymes in the liver, followed by those in the kidneys and gills seem to be most seriously affected by Cd poisoning in this fish.

Use of the fish enzyme system in monitoring water quality: effects of mercury on tissue enzymes

1. Rosy barb (Puntius conchonius) were exposed to 181 micrograms/l mercuric chloride for 48 h and the activity of acid and alkaline phosphatases (AcP and AIP), aspartate aminotransferase (AAT), alanine aminotransferase (AIAT), lactic dehydrogenase (LDH), and acetylcholinesterase (AchE) were measured in vivo in several organs. 2. The AcP activity was inhibited in the liver, gills, kidneys, and gut but stimulated in the gonads. With the exception of kidney, the AIP activity showed an increase in all the organs examined. The AAT and AIAT were generally inhibited in different organs. An increase in LDH activity occurred in the cardiac and skeletal muscles while the AchE activity was considerably lowered in the brain, gills, and liver. 3. In vitro exposure to mercury at concentrations ranging between 10(-10) and 10(-4) M, inhibited the AIP, AAT, AIAT, LDH, and AchE activities in the tissues examined. The AcP activity was also depressed in all the tissues except in the testes, in which a marginal increase was noted. 4. The in vivo and in vitro effects of Hg were not of similar quality implying sequestration of toxic cations in the intact animals.

Cimetidine-nicoumalone interaction in man: stereochemical considerations

1. The cimetidine-nicoumalone interaction was studied in five subjects who received a single 10 mg oral dose of racemic nicoumalone alone and 3 days into an oral regimen of cimetidine of 200 mg three times daily and 400 mg at night. 2. The concentrations of R(+)- and S(-)-nicoumalone in plasma were measured using a stereospecific h.p.l.c assay; augmentation of prothrombin time was used as a measure of response. 3. Cimetidine increased the rate (but not extent) of absorption of both R(+)- and S(-)-nicoumalone, and reduced the clearance of R(+)-nicoumalone but not that of the S(-)-enantiomer. 4. Cimetidine increased the anticoagulant response produced by nicoumalone in some but not all subjects, despite a consistent effect on the pharmacokinetics of the oral anti-coagulant. 5. Cimetidine appears to produce its effect by stereoselectively inhibiting the elimination of R(+)-nicoumalone.

Stereospecific assay of nicoumalone: application to pharmacokinetic studies in man

1. A stereospecific h.p.l.c. assay of nicoumalone in plasma has been developed. 2. The assay was applied to a study in which 20 mg racemic nicoumalone was given orally to three volunteers and blood samples taken for 168 h. 3. The mean pharmacokinetic parameters of the individual enantiomers were: clearance/bioavailability 1.28 1 h-1, R-enantiomer; 17.5 1 h-1, S-enantiomer: volume of distribution/bioavailability 12.5 1, R-enantiomer; 22.6 1, S-enantiomer: terminal half-life 6.8 h, R-enantiomer; 0.91 h, S-enantiomer. 4. The data are consistent with a substantial first-pass hepatic loss of S-nicoumalone.

Serum haptoglobin and alpha 1-acid glycoprotein as indicators of the effectiveness of cis-diamminedichloroplatinum (CDDP) in ovarian cancer patients--a preliminary report

Twenty-one patients with adenocarcinoma of the ovary were given a maximum of five courses of CDDP by i.v. infusion every 4 weeks. With one exception, the serum levels of both haptoglobin and alpha 1-acid glycoprotein correlate with tumour burden before therapy and at follow-up. It is suggested that a more accurate assessment of the effectiveness of CDDP therapy may be obtained by estimating these serum proteins before each infusion than by an abdominal examination.

Changes in serum acute phase proteins in ovarian cancer patients receiving cis-diamminedichloroplatinum (CDDP) infusion therapy

Nine patients with adenocarcinoma of the ovary were given a number of courses of Cisplatin, by I.V. infusion. In four patients a complete clinical response was observed and these patients are disease-free one year after treatment. There was no clinical response in the remaining five patients who have subsequently died. Serial determinations of three acute-phase reactant proteins (alpha 1-acid glycoprotein, haptoglobin, alpha 1-antitrypsin) were performed before every infusion and after therapy. Constantly high or rising serum levels of haptoglobin and alpha 1-acid glycoprotein were associated with progression of the cancer, whereas in patients who were disease-free after therapy, these glycoproteins remained essentially in the normal range. The results suggest that serial measurements of haptoglobin and alpha 1-acid glycoprotein may have clinical value as aids in deciding the effectiveness of drug therapy in these patients.

Cadmium toxicity: inducement of changes in blood and tissue metabolites in fish

The effects of acute (24 h) and chronic (90 days) cadmium (Cd) poisoning on blood and tissue metabolite levels of a teleost, Puntius conchonius were studied. Significant hyperglycemia with an increment in liver, kidney and ovary cholesterol occurred during acute Cd poisoning. By contrast, an enduring hypoglycemia and diminished levels of tissue cholesterol manifested the chronically intoxicated fish. Both acute and chronic Cd poisoning, however, caused marked hypocholesterolemia, glycogenolysis in liver and brain, and a concomitant rise in myocardium glycogen concentration. Testes cholesterol was found to be depleted after both acute and chronic (60 days) Cd poisoning.

Comparative teratogenicity of chlordiazepoxide, amitriptyline, and a combination of the two compounds in the fetal hamster

A combination of chlordiazepoxide and amitriptyline maternally administered as a single intraperitoneal injection on day 8 of gestation in the fetal hamster produced predominantly central nervous system anomalies including exencephaly and encephalocoele. In addition, omphalocoele, spinal flexion, and microcephaly were noted. A dose response relationship was found in which a maternal dose range of 13/33 mg/kg--33/83 mg/kg chlordiazepoxide/amitriptyline produced 7-92 percent fetal anomalies. Combination drug dose levels up to 23/58 mg/kg produced no maternal mortality. However, higher levels did result in a marked dose dependent mortality rate. The teratogenic potential of the combined drugs is much more pronounced than that of either drug administered alone since chlordiazepoxide at a maternal dose range of 280/3100 mg/kg produced 3-55 percent fetal anomalies, and amitriptyline at a maternal dose range of 60-100 mg/kg produced 6-45 percent fetal anomalies. The majority of these aberrant fetal developmental entities also were classifiable as exencephaly and encephalocoeles. Dose-dependent maternal mortality was observed at all dose levels for each drug administered separately.

Further observations on the corpuscles of Stannius in two Indian hill-stream teleosts

The corpuscles of Stannius in Glyptothorax pectinopterus and Pseudecheneis sulcatus occur in close proximity to the mesonephros. They are encapsulated structures comprising of secretory cells which make up a homogeneous mass in G. pectinopterus, but are arranged in complete or incomplete lobules in P. sulcatus. Based on their reaction to the aldehyde fuchsin or PAS, two types of corpuscular cells are demonstrable, and the earlier suggestion that CS have a single cell type in these two species is therefore withdrawn. The stainable cells react positively and intensely in contrast to the nonstainable ones which remain more or less colourless. Although a mixture of the two cell types comprise the CS, the stainable cells preponderate.

Haloperidol teratogenicity in the fetal hamster

Haloperidol, administered as a single intraperitoneal injection on day 8 of gestation, produced a variety of fetal malformations in hamsters. Fetal defects included exencephaly, cranioschisis, microphthalmia, anophthalmia, lower body hypodevelopment, and total body hypodevelopment. A dose-response relationship was evident as 80-245 mg/kg produced from 3 to 70% fetal anomalies.

Effect of glucagon on the principal islets of a fresh-water fish, Channa punctatus (Bloch)

Intramuscular administration of crystalline mammalian glucagon (0.5-2.0 mg/kg body weight) evokes significant cytological alterations in the principal islets of Channa punctatus, a fresh-water fish. Initially there is degeneration of the alpha-cells but later the beta-cells are also atrophied. Regressive changes in some of the alpha-cells have been interpreted to reflect their possible role in glucagon secretion. The degeneration of beta-cells appears to be secondary to the fluctuations in the blood glucose level, induced by exogenous glucagon.

Effect of cobalt salts on the glycemia and islet histology of Channa punctatus (Bloch)

Channa punctatus responds to the intramuscular administration of cobalt chloride and cobalt nitrate by exhibiting an increase in the blood glucose level. The hyperglycemia persists till 120 h, after which the fish become moribund and ultimately die. Cobalt salts evoke degranulation and vacuolization of the alpha-cells in the initial stage but later the beta-cells are also found to be severely damaged. Cobalt chloride has been found to be more toxic than the cobalt nitrate.