899 A Closed Loop Audit of Imaging Rate in Suspected Complicated Acute Diverticulitis

Aim

Diverticular disease is commonly encountered in western populations, with complicated acute diverticulitis potentially leading to significant morbidity and mortality. The National Institute for Health and Care Excellence (NICE) recommend imaging these patients within 24-hours of admission, which is essential to confirm diagnosis and guide further management. We aimed to audit the imaging rate in suspected complicated acute diverticulitis within our department and identify ways to improve this.

Method

Data were collected from all patients admitted from January to June 2021 with suspected complicated acute diverticulitis as defined by NICE. Patients with normal inflammatory markers were excluded. Electronic records were reviewed for evidence of imaging performed within 24-hours of hospital admission and the imaging rate was compared with the previous audit cycle.

Results

96 patients were admitted with suspected complicated acute diverticulitis. 83 patients had raised inflammatory markers. 76 (91.6%) of these had contrast computer tomography (CT) scans performed within 24-hours of admission. Of the 7 (8.4%) patients who did not undergo imaging within 24-hours, 3 had recent imaging suggestive of diverticular disease or diverticulitis, 2 were treated with antibiotics, 1 patient refused, and 1 had CT within 48-hours due to delays waiting for dialysis.

Conclusions

We have shown continued good compliance with NICE guidelines, though the imaging rate has declined slightly compared with the previous audit cycle (94.3%). In order to maintain and improve these standards, we will offer educational sessions within our department to underline the importance of timely imaging in this patient group and continue to audit our performance.

Resurgence from Crisis Through Awareness of Natural Inclusion

For millennia, the Western mindset has been predisposed to the inherited custom to split mind and matter, emotion and cognition, art and science, the spiritual and the intellectual, the inner and outer, contemplation and objective inquiry. Our contemporary sense of dislocation from nature has arisen from this objectivistic perception. The current societal, economic and environmental crises urge us to break down the pervasive conceptual boundaries and binary distinctions and rethink what science is or what it can become. Covid 19 has exposed the iniquities and deep fault lines in the political and economic structure of globalized modern society founded on false division or unification of individual from or with group. We see Natural Inclusionality as the path to begin to resurrect and cultivate a new normal of co-creative community from the wreckage of the old normal of cultural tyranny (Rayner, 2020). The most ground-breaking dimension of the NI perception lies in its rejection of both extremes of dualism: the narrow objectivistic view of the world as dividable into discrete entities and the equally limiting monistic view of the world as some sort of uniform oneness. We propose to unpack these insights through dialogue: an ongoing professional dialogue between two authors, between two philosophical orientations, between natural and social sciences and between science and art. Our intentions are to show Natural Inclusional awareness as humanity’s ultimate resource for a resurgence from crisis—breaching the Great Lie that isolates individual from common good. In particular, we discuss the significance of these considerations in the context of educational science and practice.

65 A Retrospective Cohort Study of the Use of Vivostat PRF Autologous Platelet-Rich Fibrin in Patient Outcomes in Total Knee Replacement Surgery

Aim

Vivostat PRF is an autologous platelet-rich fibrin spray that is prepared in theatre from the patient’s own blood and has shown that its use as a biological sealant intra-operatively reduces transfusion rates and decreases haemarthrosis after total knee replacement (TKR).

We undertook a retrospective time-based comparative cohort study examining relevant patient outcomes, comparing patients undergoing TKR surgery with Vivostat PRF versus without.

Method

106 patients undergoing TKR surgery between 2008 and 2017 were studied. Patients were selected for inclusion via hospital records and divided into two groups: those who had received Vivostat PRF intra-operatively (n = 59), and those who hadn’t (n = 47) (the control group).

Primary outcomes included haemoglobin drop pre- vs post-operatively, range of movement (ROM) at follow-up appointments, number of days post-operatively in hospital until the patient was able to manage stairs, post-operative pain scores and transfusion rates.

Results

There was a statistically significant difference in the haemoglobin drop between the two groups, with a drop of 27.5g/L in the study group compared to 31.9g/L in the control group (p = 0.019). ROM at day 3 post-operatively was better in the Vivostat group by 5.0o (p = 0.0018), and at 3 months post-operatively there was 7.8o greater movement (p = 0.004). No statistically significant differences were seen in the pain scores; however, early rehabilitation performance was improved in the Vivostat group, with a quicker time to being able to manage stairs post-operatively (p = 0.04). There was no statistically significant difference in transfusion rates.

Conclusions

This study showed that there are benefits in using Vivostat PRF in TKR surgery.

Experiences of Student Circus Arts Performers Undertaking a Shoulder Rehabilitation Program Via Telehealth Consultation During the COVID-19 Pandemic

OBJECTIVE

To explore the subjective experiences of student circus arts performers with atraumatic shoulder instability undertaking a 12-week shoulder rehabilitation program during the COVID-19 pandemic lockdown, in Melbourne, Australia.

METHODS

Using a qualitative design, 14 circus arts students from the National Institute of Circus Arts (Australia) were individually interviewed via teleconsultation. All interviews were recorded, transcribed, and analysed using inductive thematic analysis.

RESULTS

Five overarching themes were identified: (i) impact (physical and mental), (ii) opportunity, (iii) developing routine, (iv) client-therapist relationship, and (v) transformation. All participants reported positive physical changes to their shoulder including increases in strength, stability, range of motion, less pain, "clicking" and "clunking," improved posture, muscle memory, as well as carry-over to functional circus activities. The pandemic's mental impact varied across the cohort, with positive and negative experiences described in relation to cognitive, social, and affective factors. Most performers felt the pandemic provided an opportunity to focus on rehabilitation of their shoulder. The program effects were also underpinned by positive client-therapist relationships and a progressive transformation of learning where students gained knowledge of their condition, developed tools to manage their current shoulder impairment, and learned how to apply this new knowledge to future management of their condition.

CONCLUSION

A shoulder exercise intervention delivered via teleconsultation during the COVID-19 pandemic resulted in subjective reports of positive physical changes to the participants' shoulder health complaint. This was facilitated through client-physiotherapist relationships, providing structure during uncertain times, and by providing education to help in understanding their condition and its future management.

Non-tuberculous mycobacteria: a retrospective review of Scottish isolates from 2000 to 2010

There is growing recognition of the clinical importance of non-tuberculous mycobacteria (NTM), a group of versatile opportunistic bacterial pathogens. We describe the characteristics of NTM isolates in Scotland over an 11-year period using data held by the Scottish Mycobacteria Reference Laboratory. American Thoracic Society microbiological criteria were used to evaluate the clinical significance of isolates. Data presented include analysis of trends across time, species/body site associations, gender and age differences, geographical variations and the association between cystic fibrosis and Mycobacterium abscessus. We emphasise the need for standardised reporting criteria for NTM isolates to ensure optimal surveillance of NTM disease.

Systematic review of tattoo-associated skin infection with rapidly growing mycobacteria and public health investigation of a cluster in Scotland, 2010

Sporadic cases and outbreaks of tattoo-associated skin infection with rapidly growing mycobacteria have been reported although they often contain few details of public health investigations and have not previously been systematically collated. We present the details of the public health investigation of a cluster of cases, which occurred in Scotland in 2010. Investigation of the cluster involved case finding, environmental investigation of the tattoo studio and pathological and microbiological investigation of possible cases and tattoo ink. Mycobacterium chelonae was isolated from one case and three probable cases were identified. M. chelonae was grown from an opened bottle of ink sourced from the studio these cases had attended. In addition, in order to identify all published cases, we conducted a systematic review of all reported cases of tattoo-associated skin infection with rapidly growing mycobacteria. A total of 25 reports were identified, describing 71 confirmed and 71 probable cases. Mycobacteria were isolated in 71 cases and M. chelonae was cultured from 48 of these. The most frequently postulated cause of infection was the dilution of black ink with tap water. Reports of tattoo-associated rapidly growing mycobacterial skin infection are increasing in frequency. Interested agencies must work with the tattoo industry to reduce the risk of contamination during tattoo ink manufacture, distribution and application.

Evaluation of the GenoType Mycobacteria Direct assay for the simultaneous detection of the Mycobacterium tuberculosis complex and four atypical mycobacterial species in smear-positive respiratory specimens

A novel, commercially available reverse hybridization assay [GenoType Mycobacteria Direct (GTMD), version 2.0; Hain Lifescience] was evaluated for the direct detection of five clinically relevant mycobacterial species [Mycobacterium tuberculosis complex (MTBC), Mycobacterium avium, Mycobacterium malmoense, Mycobacterium kansasii and Mycobacterium intracellulare] from 54 smear-positive respiratory specimens and the findings were compared with culture results. Three approaches were used for specimen preparation using either whole or 'split' sample volumes and N-acetyl-l-cysteine/3 % NaOH or 4 % NaOH as decontamination chemicals. Forty-three out of 52 samples in which RNA amplification was successful gave GTMD results that concurred with the identification of the cultured isolate. All cases of MTBC were detected. Twenty-two samples contained M. tuberculosis complex, seven had M. kansasii, four had M. malmoense, seven contained atypical mycobacteria other than those detectable using the GTMD assay and three specimens contained no viable mycobacteria. The assay is easy to use and can be completed in one working day. Results interpretation is facilitated by the inclusion of an internal amplification control with each sample to allow identification of specimens containing amplification inhibitors. A positive GTMD result will quickly identify patients with MTBC infection or provide specific identification of four other atypical mycobacteria from the same specimen. This allows more rapid drug susceptibility testing, treatment, and public health and infection control decisions.

Human and animal infections with Mycobacterium microti, Scotland

During 1994-2005, we isolated Mycobacterium microti from 5 animals and 4 humans. Only 1 person was immunocompromised. Spoligotyping showed 3 patterns: vole type, llama type, and a new variant llama type.

Off-Pump Coronary Artery Bypass Grafting in a Heparin-Induced Thrombocytopenia Type II Patient Using Hirudin

Heparin is routinely used for anticoagulation during cardiopulmonary bypass; it is fast acting, is easily monitored, and has an antidote. Heparin-induced thrombocytopenia (HIT) can be a life-threatening condition requiring an alternative anticoagulant (hirudin) if cardiac surgical intervention is considered. At full anticoagulant doses, the effects of hirudin are difficult to monitor; therefore, we present a case in which off-pump coronary artery bypass grafting was performed in an HIT patient in whom the lower doses of hirudin could safely be monitored with easily available tests.

Antibiotic resistant tuberculosis in the United Kingdom: 1993-1999

BACKGROUND

The re-emergence of tuberculosis as a global health problem over the past two decades, accompanied by an increase in tuberculosis drug resistance, prompted the development of a comprehensive national surveillance system for tuberculosis drug resistance in 1993.

METHODS

The UK Mycobacterial Resistance Network (Mycobnet), which includes all mycobacterial reference and regional laboratories in the UK, collects a minimum dataset on all individuals from whom an initial isolate of Mycobacterium tuberculosis complex has been isolated and submitted by source hospital laboratories. Data sought include susceptibility to first line antibiotics, demographic, geographical, and risk factor information.

RESULTS

There were 25 217 reports of initial isolates of M tuberculosis complex in the UK between 1993 and 1999. All were tested for sensitivity to isoniazid, rifampicin, and ethambutol and 12 692 of the isolates were also tested for sensitivity to pyrazinamide and streptomycin. A total of 1523 (6.1%) isolates were resistant to one or more drugs, 1397 isolates (5.6%) were resistant to isoniazid with or without resistance to other drugs, and 299 (1.2%) were multidrug resistant. Although the numbers of drug resistant isolates increased over the period, the proportions remained little changed. Certain groups of people were at a higher risk of acquiring drug resistant tuberculosis including younger men, residents of London, foreign born subjects, patients with a previous history of tuberculosis and those infected with HIV.

CONCLUSION

Although the proportion of drug resistant tuberculosis cases appears to be stable in the UK at present, more than one in 20 patients has drug resistant disease at diagnosis and more than one in 100 has multidrug resistant disease. Tuberculosis control measures should be strengthened to minimise the emergence of drug resistance through rapid diagnosis, rapid identification of drug resistance, supervised treatment, and maintenance of comprehensive surveillance.

Cerebrovascular accident after vacuum-assisted venous drainage in a Fontan patient: a cautionary tale

Vacuum-assisted venous drainage was used in a 24-year-old woman who underwent a redo Fontan procedure. She developed a hemiparesis, which is thought to be caused by cerebral air embolism.

Distributed laser refrigeration

A 250-mum-diameter fiber of ytterbium-doped ZBLAN (fluorine combined with Zr, Ba, La, Al, and Na) has been cooled from room temperature. We coupled 1.0 W of laser light from a 1013-nm diode laser into the fiber. We measured the temperature of the fiber by using both fluorescence techniques and a microthermocouple. These microthermocouple measurements show that the cooled fiber can be used to refrigerate materials brought into contact with it. This, in conjunction with the use of a diode laser as the light source, demonstrates that practical solid-state laser coolers can be realized.

Comparison of three isolation systems for the culture of mycobacteria from respiratory and non-respiratory samples

AIMS

To compare the recovery of mycobacteria from clinical samples using the MB/BacT rapid culture system with that obtained using egg medium or the Bactec radiometric method.

METHODS

The three methods were compared using 681 clinical samples (462 respiratory and 219 non-respiratory samples) and eight external quality control strains. Culture media were incubated at 35-37 degrees C for six weeks in the MB/BacT system and for 12 weeks in the Bactec system and on egg medium. Solid media were examined macroscopically once a week and the Bactec vials were read six times in the first two weeks, and then weekly for the next 10 weeks (a growth index > 50 indicated a positive vial). The MB/BacT system positive vials were unloaded from the machine as soon as possible after detection. Confirmation of growth for all systems was by Ziehl-Neelson stained smears. Isolates were identified by a combination of phenotypic and molecular methods.

RESULTS

Of the 681 clinical samples, 59 (8.7%) were positive on culture, including 23 strains of Mycobacterium tuberculosis. None of the three systems recovered all of the isolates, but each recovered mycobacteria not detected by either of the other two systems. After six weeks incubation, isolation rates were 87%, 78%, and 90%, and mean times to detection were 13, 19, and nine days for the MB/BacT, egg medium, and Bactec systems, respectively. Although the MB/BacT system was slightly slower than the Bactec system, the biomass was greater, allowing earlier use of molecular probes and earlier inoculation of susceptibility tests.

CONCLUSIONS

The MB/BacT system provides comparable performance to the Bactec radiometric system, without the problems of disposal of radioactive waste. Optimal recovery is obtained when culture on egg medium is used in conjunction with a rapid culture system.

A simple and flexible blood cardioplegia delivery system

We describe a simple technique for the delivery of high haematocrit blood cardioplegia. The system allows for a user defined, variable concentration of warm, tepid or cold solution to be delivered. The concentration can be varied based upon the pressure regulated flow of blood, and is manipulated by a four variable equation calculated by a spreadsheet formula stored in a hand-held computer. The system provides a very accurate and rapid method of titration and administration of the cardioplegic solution.

Molecular evidence for heterogeneity of the multiple-drug-resistant Mycobacterium tuberculosis population in Scotland (1990 to 1997)

Multiple-drug-resistant Mycobacterium tuberculosis (MDR-MTB) has been well studied in hospitals or health care institutions and in human immunodeficiency virus-infected populations. However, the characteristics of MDR-MTB in the community have not been well investigated. An understanding of its prevalence and circulation within the community will help to estimate the problem and optimize the strategies for control and prevention of its development and transmission. In this study, MDR-MTB isolates from Scotland collected between 1990 and 1997 were characterized, along with non-drug-resistant isolates. The results showed that they were genetically diverse, suggesting they were unrelated to each other and had probably evolved independently. Several new alleles of rpoB, katG, and ahpC were identified: rpoB codon 525 (ACC-->AAC; Thr525Asn); katG codon 128 (CGG-->CAG; Arg128Gln) and codon 291 (GCT-->CCT; Ala291Pro); and the ahpC synonymous substitution at codon 6 (ATT-->ATC). One of the MDR-MTB isolates from an Asian patient had an IS6110 restriction fragment length polymorphism pattern very similar to that of the MDR-MTB W strain and had the same drug resistance-related alleles but did not have any epidemiological connection with the W strains. Additionally, a cluster of M. tuberculosis isolates was identified in our collection of 715 clinical isolates; the isolates in this cluster had genetic backgrounds very similar to those of the W strains, one of which had already developed multiple drug resistances. The diverse population of MDR-MTB in Scotland, along with a low incidence of drug-resistant M. tuberculosis, has implications for the control of the organism and prevention of its spread.

Prevalence of herpesviridae and hepatitis B virus DNA in the liver of patients with non-A, non-B fulminant hepatic failure

Members of the herpes virus family and hepatitis B virus (HBV) have been implicated as etiologic agents in non-A, non-B (NANB) fulminant hepatic failure (FHF), but the frequency of infection with these agents has not been established using appropriate controls. To examine this issue, we studied 50 NANB FHF patients and 104 liver transplant recipients from North America and Europe. Hepatic DNA was analyzed by polymerase chain reaction (PCR) for evidence of Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus I (HSV I) and II (HSV II), varicella-zoster virus (VZV), and human herpes virus-6 (HHV-6) nucleic acid sequences. The prevalence of HBV was assessed in North American subjects only. HSV I, HSV II, VZV, and HHV-6 viral sequences were not observed in any samples. Three of 50 FHF (6%) and 14 of 104 control patients (13%) were positive for CMV DNA. Two of 50 FHF (4%) and 10 of 104 control patients (10%) had EBV DNA, and HBV DNA was observed in 3 of 10 North American FHF patients (30%) and 3 of 59 controls (5%) without serum markers for HBV infection. The finding of HBV DNA in the liver of seronegative controls from North America but not Europe suggests that occult hepatitis B sequences in patients with NANB FHF may simply reflect geographic differences. The majority of cryptogenic FHF cases cannot be attributed to infection with herpes viruses or HBV.

Comparative activity of azithromycin against clinical isolates of mycobacteria

Azithromycin exhibited in-vitro activity against 20 clinical isolates of Mycobacterium avium complex for which the MIC90 was 32 mg/L and 22 clinical isolates of other mycobacteria but showed no activity against 20 isolates of Mycobacterium tuberculosis (MIC90 > 128 mg/L) nor against the single isolate of Mycobacterium marinum tested (MIC 128 mg/L). These results suggest that the drug may prove useful for the prophylaxis and treatment of infections due to non-tuberculous mycobacteria, including M. avium complex in patients with AIDS.

Commercially available versus home produced egg media for isolation of mycobacteria

AIMS

To compare the growth of clinical isolates of mycobacteria on in-house and commercial egg media.

METHODS

Fresh test media were inoculated with dilutions of the test organisms and growth, colonial morphology and microscopic appearance were compared blindly by two observers. The process was repeated after the test media had been stored for three months. The user friendliness of each of the test media was also assessed.

RESULTS

There was no difference in the microscopic appearance of any given mycobacterial species between different media. All of the test media grew the test species, although Mycobacterium bovis required four weeks on BioMerieux media, compared with two weeks on the other media. There was little obvious effect of storage on any of the media, except with M kansasii. Individual species gave characteristic colonial appearances on inhouse media; all of the commercial media gave non-specific colonial appearances that made presumptive identification very difficult. There were clear differences in the user friendliness of different media.

CONCLUSIONS

Although commercially available egg media in general gave good growth of mycobacteria, only in-house media combined good growth with useful colonial features.

A randomized prospective trial comparing single dose prostaglandin E2 vaginal gel with forewater amniotomy for induction of labour

A prospective randomized parallel-group study was carried out to compare the efficacy of a single dose vaginal prostaglandin E2 gel with forewater amniotomy for induction of labour at term in 260 parturients (110 primigravid and 150 parous women) with low risk pregnancy and favourable cervix. In the prostaglandin E2 (PGE2) managed group, the primigravidae were treated with 2 mg PGE2 gel and parous patients with 1 mg PGE2 gel. Forewater amniotomy was performed 4 h later, or sooner if women requested analgesia. In the amniotomy group, artificial forewater amniotomy was carried out and a repeat cervical assessment done 4 h later, or sooner if women requested analgesia. In both groups, intravenous oxytocin was established if there was evidence of disordered uterine activity, 6 h after the start of initial intervention. An assessment of consumers' views was carried out by using a standardized questionnaire completed 48 h after delivery. There was a significant reduction in the requirement for oxytocin augmentation in women treated with PGE2: primigravidae, odds ratio (OR), 0.27 and 95% confidence interval (CI), 0.12-0.61; multiparae, OR, 0.19 and 95% CI, 0.08-0.45. Fewer primigravidae managed with PGE2 gel required epidural analgesia (OR, 0.16; 95% CI, 0.06-1.00). Fewer parous women managed with PGE2 gel required parenteral opiates (OR, 0.44; 95% CI, 0.23-0.85) and more women required inhalation analgesia or no analgesia (OR, 2.22; 95% CI, 1.76-2.79). The intervention to delivery intervals were shortened in PGE2 groups independent of parity but the differences were not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrence of hepatitis C following orthotopic liver transplantation: a polymerase chain reaction and histological study

Hepatitis C virus was sought by nested polymerase chain reaction in the preoperative biopsy or the explanted liver of 100 consecutive adult patients undergoing orthotopic liver transplantation. In those found to be positive preoperatively, polymerase chain reaction was performed on subsequent biopsies. Of the 12 patients in whom HCV-RNA was identified in the liver by polymerase chain reaction preoperatively, viral recurrence was documented in ten of the 11 with posttransplant liver tissues available for study. In the one exception, hepatitis C virus was undetectable in the liver graft despite repeated co-amplification of albumin mRNA as an internal control, which may indicate viral clearance. In eight of the ten positive cases, HCV-RNA was also detectable in serum postoperatively, while HCV-RNA was undetectable in serum in both the cases in whom HCV-RNA was undetectable in tissue and in the patient who declined post-transplant biopsy. Two of the 12 patients infected with hepatitis C virus preoperatively have died during the follow-up period from causes unrelated to hepatitis C virus infection. While biochemical liver function in seven of those remaining has been excellent, histological evidence of at least mild chronic active hepatitis has been present in all ten cases for whom long-term biopsies are available. Three cases have progressed to severe, symptomatic chronic active hepatitis within 2 years of transplantation. Recurrent hepatitis C is associated with progressive liver disease and appreciable morbidity in a significant proportion of patients.

Detection of hepatitis "C" virus in formalin-fixed liver tissue by nested polymerase chain reaction

Interpretation of antibody to hepatitis C virus (HCV) in patients with liver disease is difficult due to false-positive reactivity in some conditions. To evaluate the feasibility of HCV in archival material, HCV was sought in formalin-fixed, paraffin-embedded liver biopsy specimens. Nested polymerase chain reaction was used to detect hepatitis C virus in formalin-fixed, paraffin-embedded liver biopsy specimens after total RNA was extracted from tissue by proteinase K digestion and phenol/chloroform purification. The relative efficiency of amplification of HCV RNA from formalin-fixed material was estimated semiquantitatively by serial dilution of cDNA synthesised from RNA extracted from fresh and formalin-fixed sections from the same liver. Although HCV RNA could be detected in formalin-fixed liver tissue by nested PCR in 5/5 cases in which HCV was detected in serum, amplification was approximately 5-fold less efficient than when HCV was amplified from fresh tissue. Nevertheless, nested PCR of HCV from formalin-fixed liver tissue represents a useful technique in addressing some important questions related to the pathogenesis of liver disease.

In vitro activity of meropenem and imipenem against mycobacteria: development of a daily antibiotic dosing schedule

The activity of two carbapenem antibiotics, meropenem and imipenem, against Mycobacterium species was assessed by means of the Bactec 460 radiometric apparatus. This system allowed a result to be read in 4-10 days. The instability of imipenem, particularly, in the test system necessitated the development of a regimen of daily addition of antibiotic to permit a more accurate assessment of antibiotic activity to be made. When antibiotic-containing media are incubated for long periods, as is the case when determining antimycobacterial activity, the stability of test antibiotics is an important factor that must be considered.

Immunolocalization of regenerating cells after submassive liver necrosis using PCNA staining

Little data exist on the proliferative state of liver cells and its relationship with various morphological findings in acute liver failure (ALF) in man. In this study we used the monoclonal antibody NCL-PCNA (clone PC-10) against the proliferating cell nuclear antigen (PCNA) to detect cycling cells in paraffin sections of 3 normal livers, 14 post-mortem needle-specimens of submassive hepatic necrosis (SHN) due to paracetamol overdosage (POD), and 10 hepatectomy specimens obtained at transplantation in patients with acute or subacute liver failure of presumed viral aetiology. In normal livers, only occasional sinusoid-lining cells were stained, whereas in SHN following POD or presumed viral hepatitis, hepatocytes of variable morphology showed significant immunoreactivity. Following POD, immunoreactivity was higher in samples taken within 5-6 days than in those obtained at 9-11 days, a pattern reminiscent of the decrease in the rate of regeneration, previously documented after partial hepatectomy in humans. Immunolabelled hepatocytes were aggregated in multiacinar 'nodules' in cases with a map-like distribution of collapsed and non-collapsed parenchyma. Ductules demonstrated comparatively less staining, but extensive labelling was exceptionally found in areas of complete hepatocellular dropout. In these areas, small elongated cells with strongly PCNA-positive ovoid nuclei, forming periportal sprouting cords or incorporated into the lining of ductules, were most remarkable in that they closely resembled 'oval cells' described in animal studies.

Interleukin-2, cisplatin, and 5-fluorouracil for patients with non-small cell lung and head/neck carcinomas

The feasibility and efficacy of treating patients with locally recurrent or metastatic non-small cell lung cancer (NSCLC) or head/neck cancer with interleukin-2 (IL-2), cisplatin, and 5-fluorouracil (5-FU) was tested. Treatment was given every 28 days and consisted of cisplatin, 100 mg/m2 on days 1 and 8; 5-FU, 1,000 mg/m2 by continuous infusion on days 1-3; and IL-2, 12 million units/m2 by i.v. bolus on days 15-19. Thirty-four patients (22 NSCLC, 12 head/neck cancer) were registered in the study. The median age was 58 years; 59% had Karnofsky performance status of 70-80% and over one-half received prior therapy. All patients were evaluable for toxicity and 29 (18 NSCLC, 11 head/neck cancer) were evaluable for response. Twenty-five patients experienced at least one grade 3 or 4 toxicity, but these toxicities were transient and, in general, well tolerated. The response rate was 37% for NSCLC (0 complete response, 7 partial response) and 55% for head/neck cancer (2 complete response, 4 partial response). Two patients with head/neck cancer responded to treatment after failing prior therapy with cisplatin/5-FU alone. The combination of IL-2, cisplatin, and 5-FU is tolerable and active for treatment of NSCLC and head/neck carcinoma; the combination may not be cross-resistant with other chemotherapy combinations. Further studies of IL-2 combined with cisplatin/5-FU are warranted to determine the most effective dose and schedule.

Use of a Radiometric Technique for Rapid Sensitivity Testing of Mycobacteria in Scotland: The First Year's Experience

We report the first year's experience of the use of a radiometric technique for sensitivity testing of mycobacterial isolates in Scotland. The techniques (using the Bactec 460 instrument) was much quicker than conventional methods (for example the mean time to obtain results for 60 strains of M.tuberculosis was 14.4 days, compared with 44.9 days for conventional methods). There was good agreement between results obtained by the two methods. Preliminary results also indicated the value of the radiometric technique for rapid isolation of mycobacteria from clinical samples (mean of 10.6 days with the radiometric technique compared with 26.7 days using egg media) although for optimal recovery, both techniques should be used in parallel.

Use of a radiometric technique for rapid sensitivity testing of mycobacteria in Scotland: the first year's experience

We report the first year's experience of the use of a radiometric technique for sensitivity testing of mycobacterial isolates in Scotland. The techniques (using the Bactec 460 instrument) was much quicker than conventional methods (for example the mean time to obtain results for 60 strains of M.tuberculosis was 14.4 days, compared with 44.9 days for conventional methods). There was good agreement between results obtained by the two methods. Preliminary results also indicated the value of the radiometric technique for rapid isolation of mycobacteria from clinical samples (mean of 10.6 days with the radiometric technique compared with 26.7 days using egg media) although for optimal recovery, both techniques should be used in parallel.

A randomized trial of continuous intravenous versus hepatic intraarterial floxuridine in patients with colorectal cancer metastatic to the liver: the Northern California Oncology Group trial

In 1983, the Northern California Oncology Group (NCOG) instituted a randomized trial of intravenous (IV) versus intraarterial (IA) floxuridine (FUDR) administered via an implantable pump for patients with colorectal cancer metastatic to the liver. The study objectives were to compare the hepatic response rate, time to hepatic progression, and toxicity for the two treatment arms. The study design, which allowed patients failing IV FUDR to crossover to the IA arm, prevents a meaningful comparative analysis of survival. Patients with liver-only metastases (N = 143) were randomized, 76 to the IV arm and 67 to the IA arm, and 115 patients (65 IV, 50 IA) were fully evaluable. Of the 65 patients in the IV arm, 28 crossed over to IA treatment after failing IV FUDR. The dose-limiting toxicity of IV FUDR was diarrhea, whereas biliary toxicity limited both the dose and duration of IA FUDR therapy. Of the first 25 patients treated with IA FUDR at a dose of .3 mg/kg/day, 10 developed radiographically evident biliary strictures, and three developed permanent jaundice. With reduction of the initial IA FUDR dose to .2 mg/kg/day, and adoption of a policy of early dosage reduction, treatment interruption, or termination of therapy for persistent elevations in alkaline phosphatase, only two further cases of serious biliary toxicity occurred. However, 26 of the 50 IA FUDR patients ultimately had therapy terminated because of drug toxicity rather than disease progression. When compared with systemic infusion, infusion into the hepatic artery greatly enhanced the antitumor activity of FUDR against colorectal liver metastases. Although biliary toxicity is the most serious limitation of this form of therapy, biliary stricture and jaundice usually can be averted through careful monitoring of liver enzymes and early dosage reduction.

An evaluation of two antigen nonspecific assays for circulating immune complexes using a model system

Two methods of detecting circulating immune complexes (CIC) in serum, the Protein A-glass fiber filter assay (PA-GFF) and the polyethylene glycol (PEG) insolubilization assay, were compared using a model system of BSA/anti-BSA. Supernatants of the quantitative precipitin curve from extreme antigen excess through antibody excess were tested by both methods. The PEG assay detected soluble CIC in all areas where expected by comparison with the Farr Test; the filter assay did not, although it did detect aggregated globulins quantitatively. The PEG assay detected high levels of CIC in serum of rheumatoid arthritis patients and low levels in normal human serum. Postprandial samples and plasma with heparin or EDTA caused unpredictable increases in results in the PEG assay so that for best results the PEG assay should be run on serum from fasting individuals. PEG insolubilized complexes were analyzed and found to contain expected serum components. A slight modification of the original method was made and tested using two other model complex systems and known CIC-containing sera. The PEG turbidity assay it fast, easy, reproducible, and suitable for quantitating and isolating immune complexes in serum.

Principles for the management of penetrating cardiac wounds

An experience with penetrating cardiac injuries between 1974 and 1977 has permitted designation of particular findings as indications for emergent operations and appropriate therapeutic approaches. Of the 46 patients with cardiac trauma, 28 suffered gunshot wounds. Seventeen patients died, and 14 of the deaths occurred as a result of asystole, ventricular fibrillation or exsanguination during operation. Two patients died of neurologic sequelae following successful cardiac repair, and one died secondary to injury not disclosed by physical examination or roentgenogram. The surviving 29 patients had five major complications. Sepsis, organ system failure and cardiac defects rarely occurred despite rapidly performed thoracotomy and severe shock. Since delayed operation has been uniformly associated with adverse outcome and because postoperative complications of emergent pericardial exploration are mild, the following conclusions have been reached: 1) Mediastinal entrance wounds, severe hypotension and signs of cardiac tamponade are demonstrative of cardiac trauma. Therefore, virtually any combination of these physical signs mandates pericardial exploration. 2) Subxiphoid or transdiaphragmatic exploration (during laparotomy) of the pericardium has been valuable in diagnosis of suspected heart wounds. 3) Emergent cardiorrhaphy is the treatment of choice. Pericardiocentesis is at best only temporarily effective. Thoracotomies performed in the emergency room were uniformly unsuccessful. If possible, cardiorrhaphy should be done in the operating room. 4) Median sternotomy is the approach of choice. 5) The basic principles of management of cardiac injury are rapid diagnosis, relief of tamponade, control of hemorrhage, repair of cardiac defects and restoration of blood volume.

Familial ichthyosis, dwarfism, mental retardation, and renal disease

The nonrandom association of congenital ichthyosis with neurologic impairment, ectodermal dysplasia, dwarfism, hypogonadism, and renal disease has prompted the review of numerous syndromes. The difficulties in characterization of syndromes in the absence of pathognomonic signs is discussed in relation to three siblings presented herein. Despite extensive investigation, underlying metabolic defects remain obscure.