Heat treatment enhances the antimicrobial activity of (+)-Catechin when combined with copper sulphate.

UNLABELLED: The aim of the study was to compare the antimicrobial activities of freshly made, heat-treated (HT) and 14 day stored (+)-Catechin solutions with (+)-catechin flavanol isomers in the presence of copper sulphate. (+)-Catechin activity was investigated when combined with different ratios of Cu(2+) ; 100°C heat treatment; autoclaving; and 14 day storage against Staphylococcus aureus. Cu(2+) -(+)-Catechin complexation, isomer structure-activity relationships, and H2 O2 generation were also investigated. Freshly made, HT, and 14 day stored flavanols showed no activity. While combined Cu(2+) -autoclaved (+)-Catechin and -HT(+)-Catechin activities were similar, HT(+)-Catechin was more active than either freshly made (+)-catechin (generating more H2 O2 ) or (-)-Epicatechin (though it generated less H2 O2 ) or 14 day-(+)-Catechin (which had similar activity to Cu(2+) controls-although it generated more H2 O2 ). When combined with Cu(2+) , in terms of rates of activity, HT(+)-Catechin was lower than (-)-Epigallocatechin gallate and greater than freshly made (+)-Catechin. Freshly made and HT(+)-Catechin formed acidic complexes with Cu(2+) as indicated by pH and UV-vis measurements although pH changes did not account for antimicrobial activity. Freshly made and HT(+)-Catechin both formed Cu(2+) complexes. The HT(+)-Catechin complex generated more H2 O2 which could explain its higher antimicrobial activity. SIGNIFICANCE AND IMPACT OF THE STUDY: Natural products attract considerable attention in the search for novel antimicrobials, prebiotics and antioxidants. Enhanced biological activity of natural products has been demonstrated with chemical and heat treatment. This article extends the few publications on heat treatments of plant products and combinations with adjuncts, to raise antimicrobial activity against pathogens such as Staphylococcus aureus. We demonstrated that heat treatment could increase the activity of (+)-Catechin, a weak antimicrobial flavanol found commonly in plants in the presence of copper sulphate. Heat treatment of readily available resources merits consideration in the development of more potent substances for use in clinical settings and agriculture.

Hepatocolonic fistula: a rare consequence of retained gallstones after laparoscopic cholecystectomy.

Spillage of gallstones during laparoscopic cholecystectomy occurs in up to 30% of cases but complications due to stone retention are less frequent. We report the first case of a hepatocolonic fistula as a consequence of a retained gallstone.

Cattle, weather and water: mapping Escherichia coli O157:H7 infections in humans in England and Scotland.

Entero-haemorrhagic Escherichia coli O157:H7 is a zoonotic pathogen, responsible for a relatively small number of food poisoning and illness outbreaks each year, when compared with other food-borne bacteria capable of causing infections in the population. Nevertheless, E. coli O157:H7 is a bacterial pathogen associated with severe human illnesses including bloody diarrhoea and haemolytic uremic syndrome occurring in both outbreak and sporadic settings. In England and Wales approximately 1% of all laboratory-confirmed cases of food poisoning are the result of E. coli O157:H7; however, in Scotland this figure increases to 3%. When the size of the population is taken into account and the rate of E. coli O157:H7 confirmed cases per 100,000 population is examined, the rate of E. coli 0157:H7 infections in Scotland is much greater than England and Wales. The routes of transmission have changed over time, with new routes of transmission such as farm visits emerging. The prevalence of E. coli O157:H7 has a seasonal dependency, with greater faecal shedding of the organism in the warmer months; this is directly mirrored in the increased reporting of E. coli O157:H7 infection among hospitalized patients. This review attempts to suggest why this phenomenon occurs, paying particular attention to weather, animal movement and private water supplies.

Antimicrobial pomegranate rind extracts: enhancement by Cu(II) and vitamin C combinations against clinical isolates of Pseudomonas aeruginosa.

Recently, natural products have been further evaluated as sources of antimicrobial agents with efficacies against a variety of microorganisms. This study reports the antimicrobial activities of pomegranate rind extract (PRE) in combination with Fe(II) and Cu(II) salts against extended-spectrum multidrug-resistant Pseudomonas aeruginosa. Antimicrobial suspension assays were carried out using aqueous extract of pomegranate alone or in combination with metals salts against P. aeruginosa. The extract:metal salt combination was also enhanced with the addition of vitamin C. Marked activities were observed for the aqueous PRE/Cu(II) preparations, which were greatly enhanced by the addition of the reductant vitamin C. In contrast, the aqueous PRE/Fe(II) preparations were inactive, regardless of addition of vitamin C. The combination of PRE and Cu(II) salts and vitamin C showed the greatest activity against clinical isolates of P. aeruginosa. These results warrant further investigation of PRE as a potential source of new antimicrobial agents.

[Laparoscopic and general surgery guided by open interventional magnetic resonance]. / Chirurgia generale e laparoscopica videoguidata dalla risonanza magnetica in configurazione open.

Interventional magnetic resonance (IMR) machines have produced unique opportunity for image-guided surgery. The open configuration design and fast pulse sequence allow virtual real time intraoperative scanning to monitor the progress of a procedure, with new images produced every 1.5 sec. This may give greater appreciation of anatomy, especially deep to the 2-dimensional laparoscopic image, and hence increase safety, reduce procedure magnitude and increase confidence in tumour resection surgery. The aim of this paper was to investigate the feasibility of performing IMR-image-guided general surgery, especially in neoplastic and laparoscopic field, reporting a single center -- St. Mary's Hospital (London, UK) -- experience. Procedures were carried out in a Signa 0.5 T General Elettric SP10 Interventional MR (General Electric Medical Systems, Milwaukee, WI, USA) with magnet-compatible instruments (titanium alloy instruments, plastic retractors and ultrasonic driven scalpel) and under general anesthesia. There were performed 10 excision biopsies of palpable benign breast tumors (on female patients), 3 excisions of skin sarcoma (dermatofibrosarcoma protuberans), 1 right hemicolectomy and 2 laparoscopic cholecystectomies. The breast lesions were localized with pre- and postcontrast (intravenous gadolinium DPTA) sagittal and axial fast multiplanar spoiled gradient recalled conventional Signa sequences; preoperative real time fast gradient recalled sequences were also obtained using the flashpoint tracking device. During right hemicolectomy intraoperative single shot fast spin echo (SSFSE) and fast spoiled gradient recalled (FSPGR) imaging of right colon were performed after installation of 150 cc of water or 1% gadolinium solution, respectively, through a Foley catheter; imaging was also obtained in an attempt to identify mesenteric lymph nodes intraoperatively. Concerning laparoscopic procedures, magnetic devices (insufflator, light source) were positioned outside scan room, the tubing and light head being passed through penetration panels. Intraoperative MR-cholangiography was performed using fast spin echo (SSFSE) techniques with minimal intensity projection 3-dimensional reconstruction. About skin sarcomas, 2 of them were skin recurrences of previously surgically treated sarcomas (all of them received preoperative biopsy) and the extent of the lesion was then determined using short tau inversion recovery (STIR) sequence. The skin was closed in each case without need for any plastic reconstruction. The breast lesions were visualized with both Signa and real-time imaging and all enhanced with contrast: 2 (20%) were visualized only after contrast enhancement; intraoperative real time imaging clearly demonstrated a resection margin in all cases. Maximum dimensions of breast specimens (range 8-50 mm, median 24.5 mm) were not significantly different from those measured by Signa (p>0.17, Student's paired t-test) or real time images (p>0.4): also there was no significant difference in lesion size between Signa and real time images (p>0.25). All postprocedure scans clearly demonstrated complete excision. The extent of the tumor at MR imaging was greater in each case than suggested by clinical examination. Adequate resection margins were planned using STIR sequences. Histological examination confirmed clear surgical margins of at least 1 cm in each case. During right hemicolectomy, both intraoperative SSFSE and FSPGR contrast imaging revealed the lesion and details of the colonic surface; imaging of the lymph node draining right colon was only partially successful, due to movement artifact. Concerning laparoscopic procedures, both FSE and SSFSE techniques produced reasonable images of the gallbladder and intrahepatic ducts, but the FSE imaging was of poor quality due to respiration artifact; however, SSFSE allowed visualization of the gallbladder and part of the common bile duct. About skin sarcomas, the extent of the tumor at MR imaging was greater in each case than suggested by clinical examination and in each case the complete tumor excision was confirmed. Histological examination confirmed clear surgical margins of at least 1 cm in each case. Intraoperative MR scanning reliably identifies palpable breast tumours and skin sarcomas and is sufficiently accurate to guide their surgical excision. Further work may be done to develop laparoscopic and open abdominal surgery as well.

Image-guided surgery for anal fistula in a 0.5T interventional MRI unit.

PURPOSE: To determine whether MR-guided anorectal surgery is feasible, and to develop techniques for MR-guided anal fistula surgery. MATERIALS AND METHODS: Six patients with pilonidal sinus (PNS), and 21 with suspected anal fistulae were operated on in the GE Signa SPIO 0.5T interventional MRI unit. Procedures were performed with magnet-safe Lockhart-Mummery fistula probes. Preprocedural and intra-operative MRI (IOMRI) techniques were used to identify the extent of the fistula tracts and septic foci, and to ensure the adequacy of the surgical procedure. RESULTS: IOMRI demonstrated the PNS lesions and the adequacy of excision. Imaging failed to demonstrate a fistula in two patients, as confirmed by surgical examination. No images were obtained in one patient due to his size (weight in excess of 100 kg). In 18 patients a fistula tract or abscess was demonstrated and IOMRI was used to assess the adequacy of the surgical procedure. In three patients this demonstrated incomplete drainage of septic foci, which was not obvious on inspection of the surgical field. We believe that in these patients IOMRI prevented an incomplete procedure and the potential requirement for a second operation. Further surgery was performed to rectify this situation. The fistula tract was laid open in 13 patients, and a Seton drain was inserted in five. CONCLUSION: MRI-guided surgery for anal fistula is feasible. IOMRI demonstrates the exact anatomy of the tracts and abscesses, and confirms that all have been adequately treated. We believe it may become particularly useful in surgery for recurrent and complex anal fistulae, and may lead to fewer recurrences.

Upright dynamic MR defaecating proctography in an open configuration MR system.

We describe our experience evaluating an MR proctography technique using an open 0.5 T MR system. Evacuation of a gadolinium-containing rectal contrast agent was dynamically imaged in the upright position using a fast gradient echo sequence. Anatomical and functional abnormalities were documented. Results from 40 patients who underwent this technique are reported. The method is proposed as an alternative to conventional fluoroscopic proctography.

Surgical management of polypoid lesions of the gallbladder.

BACKGROUND: With improvements in ultrasonography more polypoid lesions of the gallbladder (PLGs) are being detected. The management of these is controversial. METHODS: The demographic, radiological and pathological data of 38 patients with ultrasonographically detected PLGs were reviewed. A Medline search for such lesions was performed and a review of the literature is presented. RESULTS: Thirty-four patients underwent cholecystectomy and four were advised against or declined operation. Of the 34 who had cholecystectomy, 11 had macroscopic and histopathologically proven PLGs. Of these, seven had cholesterol polyps, two had adenomas, one had a carcinoid tumour and one had an adenocarcinoma of the gallbladder. One patient had a histopathologically normal gallbladder. The remainder had chronic cholecystitis with or without gallstones. All of the patients with neoplastic lesions of the gallbladder had solitary polyps greater than 1.0 cm in diameter. CONCLUSION: A protocol for the management of ultrasonographically detected PLGs is proposed. In this protocol it is suggested that patients with a PLG should undergo surgery if they are symptomatic, or if the PLG is 1.0 cm or more in diameter.

Sigmoidoscopy in a nurse-practitioner community clinic using telemedicine.

We evaluated the feasibility of remote endoscopy in a community setting. Realtime teleconsultation and telesigmoidoscopy were carried out by a nurse practitioner at a community clinic while a colorectal specialist was present at the main hospital. Rigid video-sigmoidoscopes were used and the images were transmitted via ISDN lines at 384 kbit/s. Over three months, 32 patients (mean age 35 years; 19 men and 13 women) with bleeding per rectum took part in the study. Evaluation was carried out using satisfaction questionnaires for the patients, the nurse practitioner and the clinicians. The mean grade for clarity of intraluminal views was 3.5 (1 poor, 4 excellent). Only two cases had views graded less than 3, due to the presence of excessive faecal residue. All the patients were satisfied with the teleconsultation and video-endoscopy and would return for a similar visit. User satisfaction was also high on the part of the nurse practitioner and the clinician.

Rigid videosigmoidoscopy vs conventional sigmoidoscopy. A randomized controlled study.

BACKGROUND: Not only is rigid sigmoidoscopy uncomfortable for patients, but visualisation of the rectosigmoid junction and sigmoid colon is successful in only 40-70% of examinations. A novel fine-bore rigid videosigmoidoscope is described and then compared with a rigid conventional sigmoidoscope for patient discomfort and length of insertion. METHOD: A total of 58 patients were examined with both sigmoidoscopes in a random order. Discomfort was scored on a visual analogue scale; length of insertion was scored by the surgeon. Patients were blinded to which sigmoidoscope was being used. The images from the video examination were transmitted in real time for a second opinion in a different hospital. RESULTS: The mean (SD) insertion distance of the videosigmoidoscope was 23.2 (5.9) cm, which was significantly further than with the conventional sigmoidosocpe 16.5 (3.8) cm (p < 0.01). The discomfort on a visual analogue score for the videosigmoidoscope was 3.0 (1.8), which was significantly less than for the conventional sigmoidoscope 5.5 (2.7) (p < 0.01). The five users of the equipment (four surgeons and one colorectal nurse practitioner) preferred the videosigmoidoscope for image quality and ease of examination. CONCLUSIONS: A thinner, longer, rigid videosigmoidoscope is a more effective means of looking at the proximal sigmoid colon. Despite being inserted further, it caused less discomfort than the conventional sigmoidoscope. High-quality video images can be recorded or transmitted for real-time teleconsultation.

Laparoscopic surgery in a 0.5-t interventional magnetic resonance unit.

BACKGROUND: Intraoperative imaging using magnetic resonance imaging (MRI) is now possible in interventional MR (IMR) units. Magnetic resonance imaging has potential advantages over other methods used to guide surgery. These advantages include visualization of structures deep to the two-dimensional endoscopic image and clarification of surgical anatomy. This study investigates the feasibility of laparoscopic surgery with intraoperative imaging within an IMR unit. METHODS: The procedures were performed in a 0. 5-T General Electric IMR scanner. Surgical ergonomics and intraoperative imaging were investigated by performing 10 laparoscopic cholecystectomies on porcine livers in a simulator using magnet-safe laparoscopic instruments and an ultrasonic scalpel for dissection. Intraoperative MR cholangiography (MRC) was performed using T2-weighted fast-spin-echo (FSE) and single-shot fast-spin-echo (ssFSE) techniques with maximal intensity projection (MIP) reconstruction. Two laparoscopic cholecystectomies then were performed on human patients with intraoperative MRC using similar techniques. RESULTS: The simulated procedures allowed the development of surgical techniques appropriate to this environment. Both FSE and ssFSE produced reasonable quality intraoperative images. Both patient procedures were performed without complication. The FSE imaging was of poor quality. However, ssFSE produced intraoperative images of the gallbladder with partial visualization of the extrahepatic biliary tree. CONCLUSIONS: Laparoscopic surgery in an IMR unit is technically possible. Currently, intraoperative MRC is difficult, and FSE imaging is very subject to movement artifact. However, the faster ssFSE, with further development, may be a useful technique for intraoperative imaging of the biliary tree during MR-guided surgery.

Surgical intervention in acute pancreatitis: indications, techniques and complications.

Acute pancreatitis is a disease with a significant morbidity and mortality. It has been reported as the principal diagnosis in 2% of hospital admissions with abdominal pain in the UK. The incidence is in the range of 200 to 300 cases per million population per year, but it is probably increasing. The overall mortality rate is 10 to 12%. The management of the disease and its complications requires close co-operation between surgeon, radiologist and gastroenterologist. There have been a number of improvements in the management of acute pancreatitis in the last decade.

Interventional MR-guided excisional biopsy of breast lesions.

Interventional MR (IMR) machines have produced unique opportunities for image-guided surgery. The open configuration design and fast pulse sequences allow intraoperative scanning to monitor procedures. This study was undertaken to assess the potential use of IMR for image-guided surgery. Benign breast lesion excision was chosen as an uncomplicated surgical model. Ten female patients with known benign tumors underwent excision biopsy under general anesthesia in a Signa SP10 .5-T IMR machine (General Electric Medical Systems, Milwaukee, WI). Lesions were localized with precontrast and postcontrast (intravenous gadolinium-diethylenetriamine pentaacetic acid, .2 mmol/kg) fast multiplanar spoiled gradient-recalled acquisition in the steady state (GRASS) sequences. Preoperative "real-time" fast gradient-recalled sequences were also obtained using the Flashpoint (General Electric Medical Systems, Milwaukee, WI) tracker device. The maximum dimensions of each lesion were measured from the resulting images. Excision was performed using titanium instruments and an ultrasonically activated scalpel. Intraoperative real-time scanning demonstrated the resection margin and confirmed complete excision. The maximum dimensions of the macroscopic specimens were compared with those from the MR images. All tumors were visualized with the Signa scanner and real-time imaging and the images were enhanced after intravenous contrast. Maximum dimensions on histologic examination were not significantly different from those measured from Signa (P > .17) or real-time images (P > .4). There was no significant difference between lesion size from Signa and real-time images (P > .25). All postprocedure scans demonstrated complete excision. There were six fibroadenomas, two foci of sclerosing adenosis, one area of fibrocystic disease, and one schwannoma. Intraoperative MR scanning reliably identifies palpable breast tumors and can accurately guide surgical excision. Further work using MR guidance can now be performed in other general surgical areas.

Perforated colonic carcinoma presenting as epididymo-orchitis and Fournier's gangrene.

Epididymo-orchitis is a relatively common diagnosis in elderly men, often related to prostatic outflow obstruction. A 70-year-old man presented with a 4-day history of swelling and pain in the scrotum, fevers, dysuria and frequency. He had severe symptoms of prostatic hypertrophy. Physical examination and urine microscopy confirmed the diagnosis of left epididymo-orchitis and antimicrobial therapy was commenced. Subsequently, however, he developed severe necrotizing fasciitis (Fournier's gangrene) of the scrotum requiring surgical debridement, and at laparotomy, a perforated carcinoma of the sigmoid colon was found at the level of the left deep inguinal ring. Despite further radical surgery the gangrene extended, his condition deteriorated and he died. There has been no other similar case reported in the literature, and thus, although rare, intra-peritoneal causes of infection should be considered in patients with Fournier's gangrene.

Recurrent melanoma of the leg and polypoid lesions of the gallbladder--a management dilemma.

Isolated limb perfusion (ILP) is a well-tolerated method of regional chemotherapy for melanoma, with response rates ranging from 40-80%, used to treat recurrences or metastases confined to the limb from which the original tumour was excised. We present the case of a 75-year-old woman with a third recurrence of melanoma of the left leg, referred for ILP, in whom staging investigations revealed two probable malignant polypoid lesions of the gallbladder (PLG). These were thought likely to represent metastatic melanoma. In view of the diagnostic difficulty, she underwent laparoscopic cholecystectomy together with left superficial femoral ILP. Multiple papillary adenomatosis, with dysplasia ranging from mild to severe, and with areas of invasive adenocarcinoma, were found on gallbladder histology. No previous case of this combination of tumours has been reported. This case provides evidence of an adenoma-carcinoma sequence, and to our knowledge no previous case has been reported with both carcinoma and the full range of dysplasia from mild to severe within the same gallbladder. The use of minimally invasive surgery allowed the ILP to be performed at the same operation. The pathology, natural history and place of laparoscopic surgery in the management of PLG is discussed.