Colectomy in Patients with Liver Disease: Albumin-Bilirubin Score Accurately Predicts Outcomes

BACKGROUND

Patients with liver disease undergoing colectomy have higher rates of complications and mortality. The Albumin-Bilirubin score is a recently developed system, established to predict outcomes after hepatectomy, that accounts for liver dysfunction.

METHODS

All patients undergoing colectomy were identified in the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. Demographics and outcomes were compared between patients with Albumin-Bilirubin Grade 1 vs. 2/3. Multivariable regression was performed for outcomes including colorectal-specific complications. Areas under the receiver operative characteristic curves were calculated to determine accuracy of the Albumin-Bilirubin score.

RESULTS

Of 86,273 patients identified, 48% (N=41,624) were Albumin-Bilirubin Grade 1, 45% (N=38,370) Grade 2 and 7% (N=6,279) Grade 3. Patents with Grade 2/3 compared to Grade 1 had significantly increased mortality (7.2% vs. 0.9%, p < 0.001) and serious morbidity (31% vs. 12%, p < 0.001). Colorectal-specific complications including anastomotic leak (3.7% vs. 2.8%, p < 0.001) and prolonged ileus (26% vs. 14%, p < 0.001) were higher in patients with Grade 2/3. Grade 2/3 had increased risk of mortality (odds ratio 3.07, p < 0.001) and serious morbidity (1.78, p < 0.001). Albumin-Bilirubin had excellent accuracy in predicting mortality (area under the curve 0.81, p < 0.001) and serious morbidity (0.70, p < 0.001).

CONCLUSIONS

Albumin-Bilirubin is easily calculated using only serum albumin and total bilirubin values. Grade 2/3 is associated with increased rates of mortality and morbidity following colectomy. Albumin-Bilirubin can be applied to risk-stratify patients prior to colectomy.

Trends in General Surgery Resident Experience with Colorectal Surgery: An Analysis of the Accreditation Council for Graduate Medical Education Case Logs

OBJECTIVE

Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years.

DESIGN

Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents.

SETTING

ACGME accredited general surgery residency programs.

PARTICIPANTS

Not applicable.

RESULTS

General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend.

CONCLUSIONS

The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.

Use of Preoperative Laboratory Testing Among Low-Risk Patients Undergoing Elective Anorectal Surgery

BACKGROUND

Many low-risk patients receive preoperative laboratory testing (PLT) prior to elective outpatient surgery, with no effect on postoperative outcomes. This has not been studied in patients undergoing anorectal surgery. The aim of this study was to determine if PLT in this population was predictive of perioperative complications.

MATERIALS AND METHODS

The 2015-2018 National Surgical Quality Improvement Program (NSQIP) databases were queried for elective ambulatory anorectal surgeries. PLT was defined as chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. American Society of Anesthesiologists (ASA) class 1 and 2 patients were included who underwent elective, ambulatory, benign anorectal surgery. Patient demographics, comorbidities, and postoperative outcomes were compared between those who did and did not receive PLT. Postoperative outcomes were defined as wound-related, procedure-related, major complications, unplanned readmission, and death occurring within 30 days. Multivariate regression analysis determined patient characteristics predictive of receiving testing.

RESULTS

Of 3309 patients studied, 48.6% received PLT. On multivariate analysis, older age, female sex, Black race, ASA class 2, and comorbidities were predictive of receiving testing. The complication rates were similar between patients who did and did not receive testing (4.3% versus 3.5%, P = 0.22).

CONCLUSIONS

PLT is performed in over half of low-risk patients receiving elective anorectal surgery. There was no difference in the rate of postoperative complications between patients who received testing or not, nor with normal versus abnormal results. PLT can be used more judiciously in this population.

An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis

BACKGROUND

Pathologic hemorrhoids are common among adults age 45-65. Hemorrhoids are characterized as internal or external, and grades 1-4 based on severity. The type and grade dictate treatment, with surgical treatment reserved for grades 3/4. The aim of this study is to compare clinical outcomes of various surgical treatments.

METHODS

A systematic review was conducted to identify randomized clinical trials that compare surgical treatments for grade 3/4 hemorrhoids. A Bayesian network meta-analysis was done using NetMetaXL and WinBUGS.

RESULTS

A total of 26 studies with 3137 participants and 14 surgical treatments for grade 3/4 hemorrhoids were included. Pain was less in patients with techniques such as laser (OR 0.34, CI 0.01-6.51), infrared photocoagulation (OR 0.38, CI 0.02-5.61), and stapling (OR 0.48, CI 0.19-1.25), compared to open and closed hemorrhoidectomies. There was less recurrence with Starion (OR 0.01, CI 0.00-0.46) and harmonic scalpel (OR 0.00, CI 0.00-0.49), compared to infrared photocoagulation and transanal hemorrhoidal dearterialization. Fewer postoperative clinical complications were seen with infrared photocoagulation (OR 0.04, CI 0.00-2.54) and LigaSure (OR 0.16, CI 0.03-0.79), compared to suture ligation and open hemorrhoidectomy. With Doppler-guided (OR 0.26, CI 0.05-1.51) and stapled (OR 0.36, CI 0.15-0.84) techniques, patients return to work earlier when compared to open hemorrhoidectomy and laser.

CONCLUSION

There are multiple favorable techniques without a clear "gold standard" based on current literature. Open discussion should be had between patients and physicians to guide individualized care.

Addressing Gender-Related Implicit Bias in Surgical Resident Physician Education: A Set of Guidelines

While it is the goal of academic institutions to train male and female resident physicians equally, gender-related implicit bias may play a role in resident training, thus impacting the quality and fairness of education. Implicit bias may be one of the reasons for the discrepancies that exist in resident training, specifically in learning style, evaluations by faculty members, and treatment of female residents by other clinicians. Patterns of systemic gender-related implicit bias, we argue, remain pervasive in the healthcare system and affect medical education. This review identifies areas of surgical education that are susceptible to gender-related bias and provides recommendations to safeguard gender equity in resident education. We believe behavioral change can help maintain an inclusive learning environment. Using evidence from existing data, we generated guidelines to provide surgical educators in academic centers with information to further understanding of, training in, and steps toward overcoming gender-related implicit bias in resident education. Our guidelines include specific recommendations for educators to require training modules, remove bias from teaching resources, use formal introductory titles, maintain comparable evaluations, encourage women in surgery, adjust instructional methods, and caution self-reporting.

A case report of necrotizing fasciitis with growth of Actinomyces europaeus and Actinotignum schaalii

Actinomyces europeaeus and Actinotignum schaalii are two facultative anaerobes that are common contaminants of human flora; namely the urinary tract, the female genital tract and the gastrointestinal tract. A. europeaeus has been linked with abscesses, decubitus ulcers and purulent urethritis, while A. schaalii has been associated with urinary tract infections, bacteremia and Fournier's gangrene. Here we present a case report of an 84-year-old female patient found to have a necrotizing soft tissue infection caused by A. europeaeus and A. schaalii. To our knowledge, this is the first case report that documents A. europeaeus as a causal agent of a necrotizing infection.

Preoperative bowel preparation does not favor the management of colorectal anastomotic leak

BACKGROUND

Controversy exists regarding the impact of preoperative bowel preparation on patients undergoing colorectal surgery. This is due to previous research studies, which fail to demonstrate protective effects of mechanical bowel preparation against postoperative complications. However, in recent studies, combination therapy with oral antibiotics (OAB) and mechanical bowel preparation seems to be beneficial for patients undergoing an elective colorectal operation.

AIM

To determine the association between preoperative bowel preparation and postoperative anastomotic leak management (surgical vs non-surgical).

METHODS

Patients with anastomotic leak after colorectal surgery were identified from the 2013 and 2014 Colectomy Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and were employed for analysis. Every patient was assigned to one of three following groups based on the type of preoperative bowel preparation: first group-mechanical bowel preparation in combination with OAB, second group-mechanical bowel preparation alone, and third group-no preparation.

RESULTS

A total of 652 patients had anastomotic leak after a colectomy from January 1, 2013 through December 31, 2014. Baseline characteristics were assessed and found that there were no statistically significant differences between the three groups in terms of age, gender, American Society of Anesthesiologists score, and other preoperative characteristics. A χ² test of homogeneity was conducted and there was no statistically/clinically significant difference between the three categories of bowel preparation in terms of reoperation.

CONCLUSION

The implementation of mechanical bowel preparation and antibiotic use in patients who are going to undergo a colon resection does not influence the treatment of any possible anastomotic leakage.

Acute and Chronic Gas Bubble Lesions in Cetaceans Stranded in the United Kingdom

The first evidence suggestive of in vivo gas bubble formation in cetacea, including eight animals stranded in the UK, has recently been reported. This article presents the pathologic findings from these eight UK-stranded cetaceans and two additional UK-stranded cetacean cases in detail. Hepatic gas-filled cavitary lesions (0.2-6.0 cm diameter) involving approximately 5–90% of the liver volume were found in four (two juvenile, two adult) Risso's dolphins ( Grampus griseus), three (two adult, one juvenile) common dolphins ( Delphinus delphis), an adult Blainville's beaked whale ( Mesoplodon densirostris), and an adult harbour porpoise ( Phocoena phocoena). Histopathologic examination of the seven dolphin cases with gross liver cavities revealed variable degrees of pericavitary fibrosis, microscopic, intrahepatic, spherical, nonstaining cavities (typically 50–750 μm in diameter) consistent with gas emboli within distended portal vessels and sinusoids and associated with hepatic tissue compression, hemorrhages, fibrin/organizing thrombi, and foci of acute hepatocellular necrosis. Two common dolphins also had multiple and bilateral gross renal cavities (2.0–9.0 mm diameter) that, microscopically, were consistent with acute ( n = 2) and chronic ( n = 1) arterial gas emboli-induced renal infarcts. Microscopic, bubblelike cavities were also found in mesenteric lymph node ( n = 4), adrenal ( n = 2), spleen ( n = 2), pulmonary associated lymph node ( n = 1), posterior cervical lymph node ( n = 1), and thyroid ( n = 1). No bacterial organisms were isolated from five of six cavitated livers and one of one cavitated kidneys. The etiology and pathogenesis of these lesions are not known, although a decompression-related mechanism involving embolism of intestinal gas or de novo gas bubble (emboli) development derived from tissues supersaturated with nitrogen is suspected.

A nationwide assessment comparing nonelective open with minimally invasive complex colorectal procedures

AIM

The use of minimally invasive colorectal surgery has increased greatly for both benign and malignant disease. Studies evaluating complex procedures have been largely limited to elective indications. We aimed to compare the outcome of a laparoscopic with an open transverse (TC) and total abdominal colectomy (TAC) in the nonelective setting.

METHOD

Comparative analysis was made using the Nationwide Inpatient Sample (2008-11) of patients undergoing a nonelective TC or TAC identified by ICD-9-CM procedure codes. The risk-adjusted 30-day outcome was assessed using regression modelling accounting for patient characteristics, comorbidity and surgical procedure.

RESULTS

We identified 7261 admissions including 818 laparoscopic and 6443 open procedures. The mean age of the population was 65 ± 17 years and patients in the laparoscopic group were younger (56 ± 20 vs. 66 ± 17 years; P < 0.05). The rate of a single complication was lower in the laparoscopic group (26% vs. 38%; P < 0.01), but this did not remain significant following a logistic regression analysis. Mortality was significantly lower in the laparoscopic group (3.1% vs. 17%; P < 0.01) and this remained true after adjusting for covariates (OR = 0.62; P < 0.05). Laparoscopic cases were associated with a shorter median length of stay (10 vs. 13 days; P < 0.01) and hospital charge ($75,758 vs. $98,833; P < 0.01).

CONCLUSION

A nonelective laparoscopic TC or TAC is associated with an equivalent complication rate and lower mortality compared with an open operation. The results should encourage surgeons with the appropriate skills to consider a laparoscopic approach for nonelective pathology requiring a complex colectomy.

Long-term cost-effectiveness of weight management in primary care

BACKGROUND

As obesity prevalence and health-care costs increase, Health Care providers must prevent and manage obesity cost-effectively.

METHODS

Using the 2006 NICE obesity health economic model, a primary care weight management programme (Counterweight) was analysed, evaluating costs and outcomes associated with weight gain for three obesity-related conditions (type 2 diabetes, coronary heart disease, colon cancer). Sensitivity analyses examined different scenarios of weight loss and background (untreated) weight gain.

RESULTS

Mean weight changes in Counterweight attenders was -3 kg and -2.3 kg at 12 and 24 months, both 4 kg below the expected 1 kg/year background weight gain. Counterweight delivery cost was pound59.83 per patient entered. Even assuming drop-outs/non-attenders at 12 months (55%) lost no weight and gained at the background rate, Counterweight was 'dominant' (cost-saving) under 'base-case scenario', where 12-month achieved weight loss was entirely regained over the next 2 years, returning to the expected background weight gain of 1 kg/year. Quality-adjusted Life-Year cost was pound2017 where background weight gain was limited to 0.5 kg/year, and pound2651 at 0.3 kg/year. Under a 'best-case scenario', where weights of 12-month-attenders were assumed thereafter to rise at the background rate, 4 kg below non-intervention trajectory (very close to the observed weight change), Counterweight remained 'dominant' with background weight gains 1 kg, 0.5 kg or 0.3 kg/year.

CONCLUSION

Weight management for obesity in primary care is highly cost-effective even considering only three clinical consequences. Reduced healthcare resources use could offset the total cost of providing the Counterweight Programme, as well as bringing multiple health and Quality of Life benefits.

Adoption of laparoscopic colectomy: results and implications of ASCRS hands-on course participation

INTRODUCTION

Beginning in 2003, the American Society of Colon and Rectal Surgeons has annually sponsored a laparoscopic colon and rectal surgery instructional course using a cadaver model. This study reports the adoption rate and postcourse practice patterns of participants.

METHODS

All prior participants of hands-on courses from 2003 to 2005 were asked to participate in a 25-question survey. Questions probed practice setting, prior laparoscopic experience, motivation for course participation, time to, indication for, and type of first laparoscopic colectomy, experience prior to cancer resection, factors facilitating skill acquisition, and impact on practice from course completion.

RESULTS

A total of 43 of 63 participants completed the survey and 53% had performed at least 1 laparoscopic colon resection prior to the course. A laparoscopic colon resection was performed within 1 week of the course by 52% of participants and within 1 month by 90%. Laparoscopic colectomy was performed frequently postcourse with 42% performing between 1 and 5 laparoscopic colectomies/month and 42% between 5 and 10. Hand-assisted technologies lowered the threshold for performance of first laparoscopic colectomy for 62% of participants. Cancer resection was the first procedure for 31% and 36% performed between 5 and 10 colectomies prior to cancer resection. Most important factor in particular course selection was a cadaver model (77%). A majority of the participants would require course completion prior to granting hospital privileges (73%) and would recommend the course to other surgeons (97%).

CONCLUSIONS

Cadaver course completion enables rapid integration of laparoscopic colon resection into clinical practice. Experience prior to laparoscopic resection of cancer is modest. Hand-assisted technologies promote technique acquisition.

The development of physician confidence during surgical and medical internship

BACKGROUND

While much research has addressed physician competency, the development of confidence has not been studied. We sought to identify which elements of internship residents feel most contributed to building their confidence.

METHODS

By anonymous survey, University of Pennsylvania residents rated 104 internship elements for contribution to building physician confidence and reported their subjective confidence during and since internship.

RESULTS

Two hundred ten residents in 18 specialties participated. Detailed ratings for all 104 elements are provided. Generally, independent decision-making items and good back-up support were equally highly valued, as was developing work efficiency. Poorly valued items included high patient loads, long hours, and abusive interactions. Surgical and medical residents agreed. Mean confidence increased during internship from 12 to 32 (1-100 scale) but remained in the 50s during residency for most specialties.

CONCLUSIONS

Faculty should make informed, deliberate attempts to provide those elements identified as most fostering the development of physician confidence.

Pouchitis in Ulcerative Colitis: Correlation between Predictors from Colectomy Specimens and Clinico-Histological Features

Pouchitis after restorative proctocolectomy for ulcerative colitis is usually of ill-defined etiology and is encountered with sclerosing cholangitis, bacterial overgrowth, and ischemia. Recently, appendiceal involvement, ileitis, and fissures in the colectomy specimen have been associated with short- and long-term development of pouchitis. To corroborate these recent findings, the histology of 40 colectomies (70% males; mean age 46.3 years, age range 20-70 years; mean follow-up period 3.7 years, range 1-13 years) with yearly follow-up biopsies was correlated with pouchitis and clinical symptoms. Appendicitis, fissures, and ileitis were present in 47, 45 and 5% of the patients, respectively. Pouchitis in patients with appendicitis or with fissures was noted in 44 and 50% at first biopsy and in 70 and 58% during follow-up (p = NS). Of the patients without appendicitis or without fissures, 33 and 33% demonstrated pouchitis at the first biopsy and 30 and 55% during follow-up (p = NS). Clinico-histological correlation revealed normal/near-normal biopsies with the lowest clinical severity score in 77% and with the highest clinical score in 43% (p < 0.025). The histological findings of appendiceal involvement, fissuring ulcers, and ileitis in colectomies for ulcerative colitis do not correlate with the finding of pouchitis in early or late pouch biopsies. A high clinical suspicion score is frequently not correlated with significant inflammation of the pouch.

Laparoscopic colon resection for polyps: a good novice case?

PURPOSE

Laparoscopic colon resection of the endoscopically unresectable polyp has been considered an ideal case for the surgeon with moderate laparoscopic colectomy experience because tissues are not inflamed and the lymphadenectomy may not need to be as extensive compared with that required for cancer. To assess the appropriateness of this approach, we evaluated the incidence of invasive cancer in a series of laparoscopic colon resections for polyps.

METHODS

A retrospective review was performed of 55 consecutive patients undergoing laparoscopic colon resection for endoscopically unresectable polyps during a 35-month period. Colonoscopy data, polyp characteristics, and final colon pathology were reviewed.

RESULTS

On final pathologic examination, 18.2 percent of patients had invasive adenocarcinoma. Patient age, gender, indication for colonoscopy, polyp size, polyp location, polyp characteristics, and colonoscopic biopsy pathology were not predictive of adenocarcinoma on final pathology.

CONCLUSIONS

A significant number of endoscopically unresectable polyps harbor adenocarcinoma, thereby requiring a formal lymphadenectomy at resection. Caution should be exercised when considering the laparoscopic resection of an endoscopically unresectable polyp as a "learning" case.

Photodynamic therapy with motexafin lutetium for rectal cancer: a preclinical model in the dog

PURPOSE

Local recurrence of rectal cancer remains a significant clinical problem despite multi-modality therapy. Photodynamic Therapy (PDT) is a cancer treatment which generates tumor kill through the production of singlet oxygen in cells containing a photosensitizing drug when exposed to laser light of a specific wavelength. PDT is a promising modality for prevention of local recurrence of rectal cancer for several reasons: tumor cells may selectively retain photosensitizer at higher levels than normal tissues, the pelvis after mesorectal excision is a fixed space amenable to intra-operative illumination, and PDT can generate toxicity in tissues up to 1 cm thick. This study evaluated the safety, tissue penetration of 730 nm light, normal tissue toxicity and surgical outcome in a dog model of rectal resection after motexafin lutetium-mediated photodynamic therapy.

METHODS

Ten mixed breed dogs were used. Eight dogs underwent proctectomy and low rectal end to end stapled anastomosis. Six dogs received the photosensitizing agent motexafin lutetium (MLu, Pharmacyclics, Inc., Sunnyvale, CA) of 2 mg/kg preoperatively and underwent subsequent pelvic illumination of the transected distal rectum of 730 nm light with light doses ranging from 0.5 J/cm(2) to 10 J/cm(2) three hours after drug delivery. Two dogs received light, but no drug, and underwent proctectomy and low-rectal stapled anastomosis. Two dogs underwent midline laparotomy and pelvic illumination. Light penetration in tissues was determined for small bowel, rectum, pelvic sidewall, and skin. Clinical outcomes were recorded. Animals were sacrificed at 14 days and histological evaluation was performed.

RESULTS

All dogs recovered uneventfully. No dog suffered an anastomotic leak. Severe tissue toxicity was not seen. Histological findings at necropsy revealed mild enteritis in all dogs. The excitation light penetration depths were 0.46 +/- 0.18, 0.46 +/- 0.15, and 0.69 +/- 0.39 cm, respectively, for rectum, small bowel, and peritoneum in dogs that had received MLu. For control dogs without photosensitizer MLu, the optical penetration depths were longer: 0.92 +/- 0.63, 0.67 +/- 0.10, and 1.1 +/- 0.80 cm for rectum, small bowel, and peritoneum, respectively.

CONCLUSION

Low rectal stapled anastomosis is safe when performed with MLu-mediated pelvic PDT in a dog model. Significant tissue penetration of 730 nm light into the rectum and pelvic sidewall was revealed without generation of significant toxicity or histological sequelae. Penetration depths of 730 nm light in pelvic tissue suggest that microscopic residual disease of less than 5 mm are likely to be treated adequately with MLu-mediated PDT. This approach merits further investigation as an adjuvant to total mesorectal excision and chemoradiation for rectal cancer.

Empowering primary care to tackle the obesity epidemic: the Counterweight Programme

OBJECTIVE

To improve the management of obese adults (18-75 y) in primary care.

DESIGN

Cohort study.

SETTINGS

UK primary care.

SUBJECTS

Obese patients (body mass index > or =30 kg/m(2)) or BMI> or =28 kg/m(2) with obesity-related comorbidities in 80 general practices.

INTERVENTION

The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation.

MAIN OUTCOME MEASURES

Proportion of practices trained and recruiting patients, and weight change at 12 months.

RESULTS

By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as 'completers' in that they attended the requisite number of appointments in 3, 6 and 12 months. 'Completers' achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months.

CONCLUSION

The Counterweight programme provides a promising model to improve the management of obesity in primary care.

Identification of lymphatic vessels in malignant, adenomatous and normal colonic mucosa using the novel immunostain D2-40

Distribution of lymphatic vessels in normal and neoplastic colon has been previously analyzed with electron microscopic techniques, as reliable antibodies have not been available for selective lymph vessel staining. A novel monoclonal antibody, D2-40, is recently available to differentiate lymphatic vessels from blood vessels. In this study, we analyzed the distribution of lymphatic vessels in normal colon, adenomas with and without superficial stalk invasion and invasive carcinomas without identifiable polypoid precursor lesions. In contrast to previous studies, we found lymphatic vessels in superficially misplaced stalk stroma in adenomas, and closely associated with early invasive epithelial nests in invasive lesions. Lymphatic vessels were identified within the lamina propria of the in situ aspect of in invasive tumors. We conclude that lymphatic vessel structures are seen more superficially in adenomas and invasive carcinomas than previously described. Since intramucosal carcinomas in adenomas do not metastasize, these lymph vessels may be immature or not communicate with deeper lymphatics. Proliferation and distribution of lymphatic vessels may be related to prognosis and early metastasis.

A review of Brucella sp. infection of sea mammals with particular emphasis on isolates from Scotland

Brucellae recovered from sea mammals were first reported in 1994. In the years since both culture and serological analysis have demonstrated that the infection occurs in a wide range of species of marine mammals inhabiting a vast amount of the world's oceans. Molecular studies have demonstrated that the isolates differ from those found amongst terrestrial animals and also distinguish between strains which have seals and cetaceans as their preferred hosts. At the phenotypic level seal and cetacean strains can also be differed with respect to their CO(2) requirement, primary growth on Farrells medium and metabolic activity on galactose. Two new species B. cetaceae and B. pinnipediae have been proposed as a result. This paper provides a review of Brucella in sea mammals and updates findings from the study of sea mammals from around the coast of Scotland.

Isolated lung perfusion for patients with unresectable metastases from sarcoma: a phase I trial

BACKGROUND

In patients with unresectable pulmonary metastases from sarcoma, systemic chemotherapy has had limited efficacy possibly because of dose-limiting toxicities. Isolated lung perfusion is an alternative method of delivering high-dose chemotherapy to the lungs while minimizing systemic toxicities. We present the results of our Phase I trial of isolated lung perfusion with doxorubicin hydrochloride in such a group of patients.

METHODS

From May 1995 to June 1997, 8 patients with unresectable metastases from sarcoma limited to the lungs underwent isolated lung perfusion with doxorubicin. A dose-escalation schedule starting at 40 mg/m2 was used. Seven patients were treated with a dose of 40 mg/m2 or less, and 1 patient received 80 mg/m2. Blood, tumor, and normal lung samples were obtained at various time points during the operation. Patients were evaluated for cardiac, pulmonary, and other toxicities.

RESULTS

The doxorubicin concentrations in both normal lung and tumor correlated directly with the amount of doxorubicin in the perfusate. The tumors took up less doxorubicin than the lung. All patients had minimal or undetectable systemic levels of doxorubicin at the conclusion of the perfusion. There were no cardiac or other systemic toxicities. In the 7 patients perfused with 40 mg/m2 or less of doxorubicin, there was a significant decrease in the forced expiratory volume in 1 second and a trend toward a significant decrease in diffusing capacity. The patient who received 80 mg/m2 underwent lung scanning postoperatively, and scans showed no ventilation or perfusion in the perfused lung. There were no perioperative deaths. Two patients are alive with disease, and 6 patients died of disease. The median follow-up is 11 months and the longest, 31 months. There were no partial or complete responses. One patient had stabilization of disease in the perfused lung, whereas the lesions in the untreated lung progressed markedly.

CONCLUSION

Isolated lung perfusion is well tolerated by patients and effectively delivers high doses of doxorubicin to the lung and tumor tissues while minimizing systemic toxicities. A single dose of 80 mg/m2 resulted in substantial injury to the lung. There were no partial or complete responses in patients perfused with doxorubicin at the maximum tolerated dose of 40 mg/m2. Isolated lung perfusion remains a model for testing new and innovative therapies for metastatic sarcoma.

Phocoenobacter uteri gen. nov., sp. nov., a new member of the family Pasteurellaceae Pohl (1979) 1981 isolated from a harbour porpoise (Phocoena phocoena)

Phenotypic and phylogenetic studies were performed on a Gram-negative, rod-shaped bacterium isolated from the uterus of a porpoise. Biochemical and physiological studies indicated that the bacterium was related to the family Pasteurellaceae. Comparative 16S rRNA gene sequencing studies confirmed these findings and demonstrated that the bacterium represents a hitherto unknown subline within this family of organisms. Based on the results of the phylogenetic analysis and phenotypic criteria, it is proposed that the bacterium be assigned to a new genus, Phocoenobacter uteri gen. nov., sp. nov. The type strain of Phocoenobacter uteri sp. nov. is NCTC 12872T.

Short-term growth hormone administration at the time of opportunistic infections in HIV-positive patients

OBJECTIVES

A 12-week course of recombinant human growth hormone is an effective but expensive therapy for established HIV-related wasting. Wasting in HIV disease is often episodic, coinciding with bouts of acute opportunistic infection. We hypothesized that a short course of growth hormone, targeted at the time of opportunistic infection, might improve protein metabolism thereby reducing lean tissue loss.

METHODS

HIV-infected men with acute opportunistic infections, who received standard antimicrobial treatment for their infection as well as intensive nutritional counselling and oral energy supplements, were randomized to receive growth hormone or placebo for 14 days. Principal assessments were protein metabolism (measured by 13C-leucine infusion), body composition (measured by DEXA) and safety.

RESULTS

There were no significant changes in outcome parameters in the placebo group (n = 11). In the growth hormone group (n = 9), protein catabolic rate decreased by 60% in the fasted state (P = 0.02 versus placebo), lean body mass increased by 2.2 kg (P = 0.03 versus baseline) and fat mass decreased by 0.7 kg (P = 0.002 versus baseline). There was no increase in adverse or serious adverse events in the growth hormone as compared with the placebo group.

CONCLUSIONS

A two-week course of growth hormone at the time of acute opportunistic infection in HIV-infected patients improves protein metabolism and body composition during therapy and appears to be safe. This may represent a rational and economical approach to the use of growth hormone therapy.

Jewish tradition in death and dying

Death is often a spiritually difficult time for the dying and their families. Judaism approaches dying with some unique views that can differ from other religious traditions. Through an understanding of Jewish tradition, nurses can ease the dying process for Jewish patients and their families.

Causes of death of wild birds of the family Fringillidae in Britain

The provision of supplementary food for wild birds in gardens during the winter months is common in the UK, but it is possible that it may precipitate infectious diseases in the birds. This paper describes the results of postmortem examinations of 116 wild finches carried out over a period of four years. The two commonest causes of death in areas where high mortality had been reported were infections with the bacteria Salmonella typhimurium DT40 and Escherichia coli O86. Coccidia of the genera Atoxoplasma or Isospora were found in several of the birds but were considered to be incidental. Megabacteria were also identified in some of the birds, for the first time in flocks of wild birds in the UK, but they were not considered to be significant.

Evidence for infanticide in bottlenose dolphins: an explanation for violent interactions with harbour porpoises?

Most harbour porpoises found dead on the north-east coast of Scotland show signs of attack by sympatric bottlenose dolphins, but the reason(s) for these violent interactions remain(s) unclear. Post-mortem examinations of stranded bottlenose dolphins indicate that five out of eight young calves from this same area were also killed by bottlenose dolphins. These data, together with direct observations of an aggressive interaction between an adult bottlenose dolphin and a dead bottlenose dolphin calf, provide strong evidence for infanticide in this population. The similarity in the size range of harbour porpoises and dolphin calves that showed signs of attack by bottlenose dolphins suggests that previously reported interspecific interactions could be related to this infanticidal behaviour. These findings appear to provide the first evidence of infanticide in cetaceans (whales, dolphins and porpoises). We suggest that infanticide must be considered as a factor shaping sociality in this and other species of cetaceans, and may have serious consequences for the viability of small populations.

Actinobacillus scotiae sp. nov., a new member of the family Pasteurellaceae Pohl (1979) 1981 isolated from porpoises (Phocoena phocoena)

Phenotypic and phylogenetic studies were performed on a Gram-negative, rod-shaped bacterium isolated from three porpoises. Biochemical and physiological studies indicated that the bacterium was related to the family Pasteurellaceae. Comparative 16S rRNA gene sequencing studies confirmed these findings and demonstrated that the bacterium represents a hitherto unknown subline. The nearest phylogenetic relative of the unknown bacterium was Actinobacillus delphinicola, an organism also originating from sea mammals, although a sequence divergence of 3% demonstrated that the newly isolated bacterium is a distinct species. On the basis of the results of the phylogenetic analysis and phenotypic criteria, it is proposed that the bacterium should be classified as a new species, Actinobacillus scotiae sp. nov. The type strain of Actinobacillus scotiae sp. nov. is NCTC 12922T (= M2000/95/1T).

Isolation of Escherichia coli O86:K61 producing cyto-lethal distending toxin from wild birds of the finch family

Escherichia coli was recovered from selected tissues of 43 out of a total of 46 finches found dead in the Scottish Highlands during April-May of 1994 and 1995. The isolates did not ferment sorbitol, rhamnose, sucrose or melibiose; they belonged to serogroup O86:K61, produced cytolethal distending toxin (CLDT) and possessed the eae gene sequence. The consistent recovery of organisms producing CLDT and possessing the eae gene suggests that these organisms may have played a significant role in the finch mortalities.

Priming for T-cell-mediated rejection of established tumors by cutaneous DNA immunization

DNA immunization has been shown to elicit both antibody and CTL responses against antigens expressed by infectious organisms. Because CTL responses have been implicated in rejection of cancer, we investigated whether DNA immunization by particle bombardment using a gene gun could induce CTL responses that were capable of rejecting tumors in mice. DNA immunization by particle bombardment using genes encoding beta-galactosidase and ovalbumin primed mice to generate CTLs in two genetic backgrounds (DBA/2 and C57BL/6 strains, respectively). DNA immunization was more potent in inducing CTLs than immunization with an optimized regimen of ovalbumin peptide plus immune adjuvant. Immunity induced by DNA immunization protected mice against s.c. challenge with tumors expressing the beta-galactosidase antigen. Tumors were rejected even when DNA immunization was started 3 or 7 days after tumor challenge as tumors were becoming established. Tumor rejection required CD8(+) T cells, confirming a role for CTLs in vivo. These studies show that DNA immunization by particle bombardment can efficiently induce CTL responses that are capable of rejecting even established tumors.

Epithelioid sarcoma: clinical behavior and prognostic factors of survival

BACKGROUND

Epithelioid sarcoma is a rare histologic subtype of sarcoma. The clinical behavior and prognostic factors influencing survival in this disease are examined.

METHODS

A review of clinicopathologic features of patients with epithelioid sarcoma prospectively followed between July 1982 and July 1995 at Memorial Sloan-Kettering Cancer Center was performed. Kaplan-Meier and log-rank analysis were used.

RESULTS

Eleven men (69%) and five women (31%) were treated during this period. Mean age at diagnosis was 33 years, and length of symptoms before diagnosis was 18 months. Tumors presented in the trunk in 44% of patients, the lower extremity in 31%, and the upper extremity in 25%. Median follow-up time was 45 months. At least one local recurrence was experienced by 69% of patients. Metastases to regional lymph nodes during the course of the disease developed in 44% of patients and to the lungs in 44%. Median survival was 88.8 months, with a 66% 5-year survival rate. Pulmonary metastasis was correlated with decreased survival.

CONCLUSIONS

A delay in diagnosis of epithelioid sarcoma is common. Epithelioid sarcoma differs from other sarcoma subtypes in propensity for nodal spread and local recurrence. Careful follow-up evaluating local recurrence, nodal spread, and pulmonary metastases is warranted.

Establishment of an experimental intrapulmonary tumor nodule model

BACKGROUND

A pulmonary tumor model is necessary to study the biology and therapy of lung cancer. Methods to establish a solitary intrapulmonary nodule are not well defined. Two methods for solitary intrapulmonary tumor nodule development in the Fischer rat are described.

METHODS

Methylcholanthrene-induced sarcoma cell suspensions were introduced into lung parenchyma of Fischer rats via limited thoracotomy and lung puncture, or instilled into a distal airway after tracheal puncture and catheterization. Intrapulmonary tumor location, implantation mortality, procedure length, and animal survival were recorded.

RESULTS

Single pulmonary nodules developed at the implanted position in 100% (n = 320) and 95% (62/65) of animals after direct injection into the pulmonary parenchyma or via tracheal puncture and instillation. Operative mortality was 2% and 5% via lung or tracheal implantation, respectively. Less than 5 minutes was required for each implantation. Mean survival time was 24 +/- 2 and 26 +/- 6 days after lung or tracheal implantation in animals allowed to survive until tumor-induced death.

CONCLUSIONS

These easily performed, reproducible methods of establishing solitary intrapulmonary tumors are useful tools for lung cancer research.

Staphylococcus lutrae sp. nov., a new coagulase-positive species isolated from otters

Phenotypic and phylogenetic studies were performed with three strains of a catalase-positive, gram-positive, coccus-shaped bacterium isolated from otters. The results of a 16S rRNA gene sequence analysis demonstrated that these strains represent a hitherto unknown subline within the genus Staphylococcus. Based on the results of the phylogenetic analysis and phenotypic criteria, we propose that these bacteria should be classified as members of a new species, Staphylococcus lutrae. The type strain of S. lutrae is DSM 10244.

Adenoviral thymidine kinase prodrug gene therapy inhibits sarcoma growth in vivo

Local recurrence of sarcoma is due to residual tumor cells remaining after surgical resection and is associated with decreased survival. We implemented adenoviral-mediated transfer of the herpes simplex thymidine kinase (HSTK) gene with subsequent ganciclovir (GCV) administration to treat a model of residual sarcoma, [3H]Thymidine uptake in MCA sarcoma cells was determined after infection with replication incompetent adenovirus of the AdMLP.HSTK construct in the presence of GCV. In vivo efficacy was evaluated in a model of residual sarcoma when 9 mg of MCA tumor was implanted into the latissimus muscle of Fischer 344 rats. Three days after implantation, animals were randomized to receive AdMLP.HSTK, AdCMV. Null, or viral suspension buffer intratumorally. From Day 4, animals were administered b.i.d. GCV (50 mg/kg) or saline ip. Tumors were excised on Day 14 and weighed. Statistical analysis was by Mann-Whitney U test. In vitro: [3H]thymidine incorporation was significantly decreased in MCA sarcoma cells infected with AdMLP.HSTK in the presence of GCV (P < 0.05). In vivo: Growth of MCA sarcoma treated with AdMLP.HSTK and GCV was significantly inhibited. Final tumor weights in the AdMLP.HSTK/GCV group were lower than all control groups (P < 0.05). A significant antitumor growth effect on MCA sarcoma was seen with adenoviral-mediated transfer of the HSTK gene and GCV administration, both in vitro and in an in vivo model of residual disease. This prodrug gene therapy strategy warrants investigation as an adjuvant modality in the management of sarcoma.

Sequential bilateral isolated lung perfusion in the rat: an experimental model

BACKGROUND

A model of isolated single-lung perfusion in the rat has been established in our laboratory to study the chemotherapeutic treatment of pulmonary metastases. A sequential bilateral isolated lung perfusion model was designed to investigate the feasibility of staged perfusions in the rat.

METHODS

Twenty-four Fischer rats were randomized into three experimental groups of 8 rats each. All rats underwent left isolated lung perfusion. One, 2, or 3 weeks later, the rats in groups I, II, and III, respectively, underwent contralateral (right) perfusion. Five control animals (group IV) underwent sequential bilateral sham thoracotomies 1 week apart. Arterial blood gas analysis was performed 1 week after the second operation in the rats in groups I and IV.

RESULTS

All animals survived the first operation, with 100% (8/8), 75% (6/8), and 100% (8/8) of the animals in perfusion groups I, II, and III, respectively, surviving the second operation. All control animals (group IV) survived the second sham thoracotomy. Arterial blood gas analysis did not show a significant difference in the oxygen or carbon dioxide partial pressure or the pH between group I and IV (p = 0.32, 0.96, and 0.76, respectively).

CONCLUSIONS

Our experiments demonstrate that sequential bilateral isolated lung perfusion is safe in and well tolerated by the rat. This model can be used to investigate the safety and efficacy of staged perfusions with chemotherapeutic agents in the treatment of bilateral pulmonary metastases in the rat.

Nonoperative management of tracheal laceration during endotracheal intubation

Tracheal laceration is a rare but potentially devastating complication of endotracheal intubation. Traditional management of intubation-related tracheal laceration is operative. Nonoperative management of a woman noted to have a tracheal laceration during intubation is described. Criteria by which nonoperative treatment can be considered are outlined.

Resection for cure of adenocarcinoma of the head of the pancreas: the greater Hartford experience

BACKGROUND

Nationally, the results of pancreaticoduodenectomy for adenocarcinoma of the pancreas have improved. Therefore, we examined our experience with this operation.

METHODS

A retrospective review of tumor registry data from four greater Hartford, Connecticut, hospitals identified 51 patients who underwent pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas between 1982 and 1992.

RESULTS

The 30-day operative mortality rate for the group was 4%. Life table survival analysis revealed a five-year survival rate of 15% and a median survival of 15 months. Twelve patients had postoperative radiation therapy and chemotherapy. The median survival in this group was 36 months, significantly longer than that of the nonadjuvant therapy group (13 months, P < .02). No difference in operative mortality or ultimate survival was seen between the hospital with the largest experience and the three other hospitals.

CONCLUSIONS

Pancreaticoduodenectomy can be performed safely at hospitals with relatively low pancreaticoduodenectomy volume. Survival rates are longer than in past reviews.

Isolated lung perfusion with melphalan for the treatment of metastatic pulmonary sarcoma

OBJECTIVE

Isolated lung perfusion allows the delivery of high-dose chemotherapy to the perfused lung and is an efficacious modality in the treatment of pulmonary metastases in the rat. Melphalan activity in this model was investigated.

METHODS

TOXICITY STUDY: Maximum tolerated dose of melphalan delivered by means of isolated lung perfusion was determined by survival after contralateral pneumonectomy. PHARMACOKINETICS STUDY: Nineteen rats were treated with melphalan administered either by isolated lung perfusion (2 mg) or intravenously (2 mg or 1 mg). Lung, pulmonary effluent, and serum melphalan were analyzed by high-pressure liquid chromatography. EFFICACY STUDY: On day 0, 41 rats received an intravenous injection of 5 x 10(6) methylcholanthrene induced sarcoma cells. On day 7, rats either received intravenous melphalan (2 mg [n = 10]; 1 mg [n = 8]) or underwent left isolated lung perfusion with 2 mg of melphalan (n = 12). Isolated lung perfusion with buffered hetastarch in sodium chloride (Hespan, n = 11) was used as control. On day 14, pulmonary nodules were counted.

RESULTS

TOXICITY

Maximum tolerated dose of melphalan delivered buy means of isolated lung perfusion was 2 mg.

PHARMACOKINETICS

Left lung melphalan level was significantly higher in the isolated lung perfusion group (62.2 +/- 34.3 microg/gm lung) than in the intravenous treatment groups (6.9 +/- 1.9 microg/gm lung and 3.3 +/- 0.9 microg/gm lung, respectively) (p = 0.0002).

EFFICACY

Significantly fewer left lung nodules were found in animals receiving melphalan by means of isolated lung perfusion (7 +/- 10) than in the groups receiving intravenous melphalan (60 +/- 21) or buffered hetastarch by isolated lung perfusion (84 +/- 52) (p = 0.01 and p = 0.0001, respectively).

CONCLUSION

Isolated lung perfusion with melphalan is safe and effective in the treatment of pulmonary sarcoma metastases in the rat.

The metabolic response to opportunistic infections in AIDS

OBJECTIVE

The metabolic response to AIDS-defining opportunistic infections was examined to provide a logical basis for the management of associated weight loss.

DESIGN

A prospective study of metabolism in AIDS.

SETTING

HIV outpatients' department and wards at the Chelsea and Westminster Hospital, London.

PATIENTS

Ten asymptomatic Centers for Disease Control and Prevention stage II HIV-seropositive control subjects and 36 HIV-seropositive patients with a single newly diagnosed and untreated opportunistic infection [10 with microsporidial or cryptosporidial diarrhoea, 10 with Pneumocystis carinii pneumonia, nine with cytomegalovirus enteritis and seven with systemic Mycobacterium avium-intracellulare].

MAIN OUTCOME MEASUREMENTS

Subjects had measurements of resting energy expenditure using indirect calorimetry and of body composition using dual energy X-ray absorptiometry.

RESULTS

Subjects with protozoal diarrhoea had a decreased resting energy expenditure (P < 0.05) and decreased body fat (P < 0.01). Subjects with P. carinii pneumonia had an elevated resting energy expenditure (P < 0.05). Subjects with systemic M. avium-intracellulare had an elevated resting energy expenditure (P < 0.05) and decreased skeletal muscle mass (P < 0.05). Subjects with cytomegalovirus enteritis had a non-significant elevation of resting energy expenditure with a non-significant loss of both fat and lean tissue.

CONCLUSION

Subjects with protozoal diarrhoea show a starvation response to infection and subjects with systemic M. avium-intracellulare show a cachectic response. Since there is a variation in the metabolic response to opportunistic infection in AIDS patients, nutritional management should be directed according to the specific cause.

Energy balance in asymptomatic HIV infection

OBJECTIVES

Body weight is regulated by the balance between energy intake and energy expenditure, but the influence of HIV infection on energy balance has not been fully examined. The main objectives of this study were (1) to assess the effect of HIV on energy balance, (2) to examine the relationship of parameters of immunodeficiency to energy balance, and (3) to examine the interrelationship of different components of energy balance in asymptomatic HIV-seropositive men.

DESIGN

A cross-sectional study of nutrition and metabolism in asymptomatic HIV-seropositive men

METHODS

Components of energy balance were examined in 104 asymptomatic HIV-seropositive men (CD4 count 4-482 x 10(6)/l) and 57 age-matched HIV-seronegative male controls. Energy and protein intake were measured using 5-day diaries, and small bowel absorption and permeability was assessed using four sugar probes. Resting energy expenditure was calculated from indirect calorimetry and nitrogen loss estimated from 24 h urine collection. Four methods were used to assess the effect of HIV infection on body composition (anthropometry, dual energy X-ray absorptiometry, bioelectrical impedance and 24 h urine creatinine).

RESULTS

Resting energy expenditure per kilogram of fat-free mass was raised (P < 0.0001), fat mass was decreased (P = 0.001), fat-free mass was increased (P = 0.05), energy intake was higher (P = 0.05), absorption of L-rhamnose (P = 0.01) and 3-O-methyl-D-glucose was decreased (P = 0.003), and small bowel permeability was increased (P < 0.0001) in HIV-seropositive men compared with HIV-seronegative controls. HIV-seropositive subjects with a CD4 count less than 100 x 10(6)/l had decreased absorption of L-rhamnose (P < 0.05), D-xylose (P < 0.05) and 3-O-methyl-D glucose (P < 0.05) compared with HIV-seropositive subjects at higher CD4 counts, and had a similar resting energy expenditure to HIV-seronegative controls. Protein intake, carbohydrate, fat and protein oxidation. 24 h nitrogen excretion and appendicular muscle mass were similar in HIV-seropositive men and controls.

CONCLUSION

HIV infection exerts a direct effect on parameters of energy balance that varies with the severity of immunosuppression.

Actinobacillus delphinicola sp. nov., a new member of the family Pasteurellaceae Pohl (1979) 1981 isolated from sea mammals

We performed phenotypic and phylogenetic studies of a gram-negative, rod-shaped bacterium isolated from cetaceans. The results of a 16S rRNA gene sequence analysis demonstrated that this bacterium represents a previously unknown line of descent in the family Pasteurellaceae. On the basis of the results of our phylogenetic analysis and phenotypic criteria, we propose that this organism should be classified as a new species, Actinobacillus delphinicola sp. nov. The type strain of A. delphinicola sp. nov. is strain NCTC 12870.

Isolation of Brucella species from cetaceans, seals and an otter

Brucella organisms which differed from the recognised species of the genus, were isolated from nine seals, eight cetaceans and one otter. A method is described for the isolation of Brucella species from sea mammals and the first isolations of Brucella species are recorded from an Atlantic white-sided dolphin (Lagenorhynchus acutus), two striped dolphins (Stenella coeuleoalba), a hooded seal (Cystophora cristata), a grey seal (Halichoerus grypus) and a European otter (Lutra lutra). There were differences in the culture media required for the primary isolation of the organisms and in their dependency on carbon dioxide, Subcutaneous lesions, when present, always yielded a confluent growth. The organisms were isolated from seven of 14 spleen samples and also from the mammary glands, uterus, testes and blood and the mandibular, gastric, iliac, sub-lumbar and colorectal lymph nodes.

Cetobacterium ceti gen. nov., sp. nov., a new gram-negative obligate anaerobe from sea mammals

Phenotypic and phylogenetic studies were performed on a Gram-negative obligately anaerobic rod-shaped bacterium isolated from two sea mammals. 16S rRNA gene sequence analysis demonstrated the bacterium represents a hitherto unknown line of descent peripherally associated to the fusobacteria and low G+C relatives. Based on the result of the phylogenetic analysis and phenotypic criteria, it is proposed that the bacterium should be assigned to a new genus, Cetobacterium ceti gen. nov., sp. nov. The type strain of Cetobacterium ceti sp. nov. is NCFB 3026.

Organochlorine residues in harbour porpoise and bottlenose dolphins stranded on the coast of Scotland, 1988-1991

The organochlorine (OC) residues, chlorobiphenyls (CBs), DDT and its metabolites, dieldrin, hexachlorobenzene and technical chlordane mixtures have been determined in the blubber of harbour porpoise and bottlenose dolphins from around the north and east coasts of Scotland as a result of strandings and bycatches between 1988 and 1991. The concentrations of OCs range from some of the lowest values reported at 280 micrograms kg-1 for t-CBs, 145 micrograms kg-1 for t-DDT and 71 micrograms kg-1 for dieldrin to some of the highest values, 23,000 micrograms kg-1 for t-CBs, and 10,200 micrograms kg-1 for t-DDT. OC levels were correlated with the age and sex of the sample of harbour porpoise and bottlenose dolphins from the Moray Firth area. The study confirms that the concentration of these compounds is highly dependent on co-factors of age and sex, and that data from single or small numbers of animals may be of limited value in comparing information on organochlorine residues in mammals within or between regions.