Caring for patients with spinal metastasis during an MRI examination

INTRODUCTION

Magnetic resonance imaging (MRI) is without question the best tool used for diagnosing and evaluating spinal metastasis. An MRI examination is known to be of great value for the treatment planning and survival of these patients. Radiographers have an important role in how the quality of care is experienced by the patients during an MRI examination. The purpose of the study was to describe the radiographers' perceptions of caring for patients with spinal metastasis during an examination with MRI.

METHODS

Phenomenography was used to analyze the data in this study. Ten radiographers, one male and nine females were interviewed about their perception of caring for patients with spinal metastasis during an MRI examination.

RESULTS

The findings showed that the radiographers' caring perspective influenced their approach towards what they consider to be essential in the care of patients with spinal metastasis. This can impact the extent of the adjustment to the care needs of the patients. Furthermore, the findings showed that there was a strong connection between the radiographers' care approach and preparedness to personalize the care.

CONCLUSION

This study shows that it is important to be flexible when providing care for the patients. A person-centered care is achieved when the caring perspective is based on the patient's view and adjustments are made in agreement with the patient.

Group housing of male CD1 mice: reflections from toxicity studies

Owing to their naturally aggressive behaviour, male mice are often housed individually in toxicity studies. However, several publications advocate group-housing of mice to enable normal social behaviour and interactions between the animals. This refinement project aimed at facilitate group-housing in toxicity studies. A handling procedure, including key factors such as allocation into groups before sexual maturation, transfer of used nesting material into clean cages and avoidance of external changes, that makes group-housing of male CD-1 mice possible in long-term toxicity studies has been developed at Safety Assessment within AstraZeneca, Sweden. Observations on the effect on aggression/fighting in group-housed male mice following different procedures performed in toxicity studies have shown that temporary removal of animals from the group for blood or urine sampling does not affect the group dynamics. However, temporary removal of animals for mating leads to fighting if the animals are taken back to the original group. Treatment with test compound might affect the general condition of the animals and the social hierarchy could be changed. In such cases aggression/fighting might occur and the animals have to be separated. Our experience clearly indicates that group housing of male mice in long-term studies leads to more easily handled animals, as compared with individually housed mice.

Impact of extended written information on patient anxiety and image motion artifacts during magnetic resonance imaging

PURPOSE

To evaluate whether increased written information to patients prior to magnetic resonance imaging (MRI) decreases patient anxiety and image motion artifacts.

MATERIAL AND METHODS

A two-group controlled experimental design was used. Of 242 patients, 118 received routinely given basic written information (control group) while 124 were given increased written information (intervention group). To measure patient anxiety before and during scanning, the self-report psychometric test State-Trait Anxiety Inventory (STAI) was used. After MR examination, the patients answered a questionnaire on satisfaction with the written information. The images were assessed with regard to motion artifacts.

RESULTS

Motion artifacts were present in fewer patient images in the intervention group than in the control group (4.0% versus 15.4%,; P=0.003). There was no significant difference between the control and the intervention group regarding patient anxiety and satisfaction with the information. Women in both groups showed a higher level of anxiety than the men did.

CONCLUSION

Increased information about the MRI scanning procedure and expected experiences during the scan may help patients to lie still during the sequences, with a decrease in motion artifacts. However, further research is needed to evaluate the effect of other interventions on patient anxiety during MRI scanning.

Staphylococcus lugdunensis: clinical spectrum, antibiotic susceptibility, and phenotypic and genotypic patterns of 39 isolates

Staphylococcus lugdunensis is a member of the coagulase-negative staphylococci with the potential to cause clinically significant infections. The spectrum of infections was investigated in 39 isolates of S. lugdunensis from 38 patients. Most (73%) infections were located below the waist, while those above the waist were mainly (5/7) breast abscesses. Most isolates were susceptible to the antibiotics tested, although 15.4% were beta-lactamase-positive and could be identified by the disk-diffusion method for penicillin G. There was very good concordance between the disk-diffusion method and the Etest method for oxacillin resistance. Pulsed-field gel electrophoresis (PFGE) showed that 56% of the isolates belonged to one SmaI pulsotype, while phenotypic analysis by the Phene Plate system identified three main phenotypic groups. Although the S. lugdunensis isolates analysed were obtained from different patients, treated in different wards and hospitals during a 4-year period, there was a low degree of diversity, both genotypically and phenotypically. For this reason, PFGE is not suitable for the analysis of an outbreak situation, and the homogeneity observed may indicate that S. lugdunensis is a genetically conserved species of coagulase-negative Staphylococcus.

Accuracy of segmented MR velocity mapping to measure small vessel pulsatile flow in a phantom simulating cardiac motion

The purpose of this study was to investigate the accuracy of conventional, segmented, and echo-shared MR velocity mapping sequences to measure pulsatile flow in small moving vessels using a phantom with simulated cardiac motion. The phantom moved either cyclically in-plane, through-plane, in- and through-plane, or was stationary. The mean error in average flow was -2% +/- 3% (mean +/- SD) for all sequences under all conditions, with or without background correction, as long as the region of interest (ROI) size was equal to the vessel cross-sectional size. Overestimation of flow as a result of an oversized ROI was less than 20%, and independent of field of view (FOV) and matrix, as long as the offset in angle between the imaging plane and flow direction was less than 10 degrees. Segmented velocity mapping sequences are surprisingly accurate in measuring average flow and render flow profiles in small moving vessels despite the blurring in the images due to vessel motion. J. Magn. Reson. Imaging 2001;13:722-728.

Trovafloxacin susceptibility of aerobic clinical bacterial isolates from Sweden

Trovafloxacin susceptibility was studied in aerobic clinical isolates of bacterial pathogens from 5 microbiology laboratories in Sweden. Trovafloxacin and ciprofloxacin minimum inhibitory concentration (MIC) determinations were performed on 474 clinical isolates. Disk diffusion tests using trovafloxacin and ciprofloxacin 10 microg disks were performed on a total of 7142 clinical isolates (trovafloxacin). Susceptibility interpretations for trovafloxacin and ciprofloxacin were determined from MIC values and disk diffusion tests using species-related MIC-limits and zone diameter breakpoints. Eight of 12 gram-positive species groups were fully susceptible to trovafloxacin as judged by MIC tests. Trovafloxacin gave MIC50 values of 0.032 mg/l for S. aureus, 1.0 mg/l for MRSA, 0.064 mg/l for coagulase negative staphylococci, 1.0 mg/l for MRSE, 0.064 mg/l for S. saprophyticus, 0.125 mg/l for group A and group B streptococci, 0.064 mg/l for group C and G streptococci and S. pneumoniae, 0.25 mg/l for E. faecalis, and 16.0 mg/l for E. faecium. These MIC values were 4-16-fold lower than those of ciprofloxacin. Both MIC and disk tests showed similar levels of susceptibility among gram-negative isolates for trovafloxacin and ciprofloxacin. For most gram-negative species the trovafloxacin MIC50 values were similar to or slightly higher than those for ciprofloxacin. Trovafloxacin MIC values were much lower for Acinetobacter strains, but higher for P. mirabilis compared with ciprofloxacin. The favourable susceptibility levels of Swedish aerobic pathogens to trovafloxacin emphasize the potential of this drug for the treatment of serious infections.

Calibration of disk diffusion antibiotic susceptibility testing: species-related trovafloxacin interpretive zone breakpoints and selection of disk potency

International comparisons of antibiotic susceptibility require the use of common minimum inhibitory concentration (MIC) limits. Disk diffusion test results are not directly suitable for such comparisons, since different standards are often used and zone breakpoints issued might reflect different MIC limits. We have used single strain regression analysis (SRA) for the calibration of the disk test, both according to species and individual laboratory, and for quality control of trovafloxacin disk diffusion tests in 5 laboratories in Sweden. Preliminary controls using histogram analysis including subtraction histograms of reference strains revealed marked differences between different laboratories. SRA was performed on 4 reference strains, S. aureus, E. faecalis, E. coli and P. aeruginosa, using disks containing 1, 3, 10, 30 and 100 microg trovafloxacin. The results using SRA showed a difference between laboratories using Biodisk PDM medium, which produced smaller zones, and those using Oxoid IsoSensitest. Species-related regression lines for laboratories using either medium were calculated and corresponding interpretive zone breakpoints determined for MIC limits. Rational criteria for the selection of a suitable disk content of an antibiotic were also defined and applied to trovafloxacin. The 10 microg disk selected by NCCLS (National Committee for Clinical Laboratory Standards) proved optimal.

Septic arthritis caused by a gram-negative bacterium representing a new species related to the Bordetella-Alcaligenes complex

A knee-joint exudate culture yielded on two occasions a gram-negative bacterium. Regular methods for speciation did not provide an identification. The infection was successfully treated with ciprofloxacin. The unknown isolate, CCUG 36768, was subjected to further investigation, including 16S rDNA sequencing, protein profiling, cellular fatty acid analysis, and various biochemical tests, in order to produce a species identification. The 1469 bp-long 16S rDNA sequence did not reveal identity with any known species sequence. CCUG 36768 clustered in a group of species, including Alcaligenes defragrans, Denitrobacter permanens, Taylorella equigenitalis, Alcaligenes faecalis, and four strains of Alcaligenes species without a specific species name. Bordetella species also showed a high degree of similarity with CCUG 36768. Protein profiling, cellular fatty acid analysis and computer-assisted analysis of biochemical profiles indicated similarity with Bordetella-Alcaligenes species, often close to B. holmesii and B. avium. API 20 NE indicated the profile of Moraxella species of poor identity. It is concluded that CCUG 36768 represents a new bacterial species of pathogenic potential in humans. It is related to the Bordetella-Alcaligenes group. Powerful new methods for speciation are available and it is recommended that unknown isolates from normally sterile sites be submitted for further analysis. Several isolates are required for the definition of new species.

PCR assay or culture for diagnosis of Bordetella pertussis in the routine diagnostic laboratory?

A nested PCR method was compared with culture for the detection of Bordetella pertussis in a routine clinical diagnostic laboratory. A total of 241 clinical nasopharyngeal aspirates were examined in parallel in the laboratory. Both methods were positive for 75 samples (31%), eight samples were positive by nested PCR only (3.3%), and one sample was positive by culture only (0.4%). The mean time actually required in the clinical laboratory (not operating with pertussis diagnosis during weekends) from the day of arrival to the diagnosis of a positive or negative sample by the nested PCR assay was 1.8 +/- 1.3 days (mean +/- SD), for positive culture 4.5 +/- 1.4 days and for negative culture 10.5 +/- 1.0 days. The hands-on time in the laboratory to perform the nested PCR was 2 h, for a positive culture 25 min, and for a negative culture 15 min. The cost analysis of the methods, when running one sample at a time, showed that the laboratory cost for PCR was six times higher than culture. When running four samples together the cost for PCR was three times higher than culture. In conclusion, the nested PCR is the more rapid and sensitive method compared to culture. With the present design, the PCR-protocol involves higher material expenditure and claims more hands-on time.

Complement and clusterin in the injured nervous system

Peripheral nerve injury and neuronal degeneration resulting from toxic ricin induce activation of the classical pathway of complement close to the injured motorneuron perikarya or sensory terminals. In contrast, degeneration of central myelinated fibers is not accompanied by complement expression. The main source of complement in peripheral nerve injury and toxic ricin degeneration appears to be microglia. Brain contusion is associated with complement activation. Some of the complement in this situation may derive from plasma, because the blood-brain barrier is disrupted. Clusterin expression is increased in astrocytes along with their activation in the vicinity of lesioned neurons. In addition, axotomized motorneurons show a marked clusterin upregulation. A relationship between clusterin and cell death is suggested by the prominent aggregation of clusterin in neuronal perikarya destroyed by the effects of toxic ricin, as well as by the neosynthesis of clusterin in apparently degenerating nonneuronal cells, presumed to be oligodendrocytes. Our findings indicate that the expression of complement and clusterin are prominent features of neural degeneration and regeneration, as it is in Alzheimer's disease brains as well. The nerve injury conditions described, therefore, offer attractive experimental models to elucidate the roles of these molecular components in neurodegenerative disorders, thereby providing useful insights into potentially new therapeutic approaches in these conditions.

Complement and clusterin in the spinal cord dorsal horn and gracile nucleus following sciatic nerve injury in the adult rat

We provide evidence for activation of the complement cascade in the dorsal horn of the spinal cord and in the gracile nucleus in the brainstem following sciatic nerve transection in the adult rat. Immunocytochemical analyses showed immunoreactivity for endogenous immunoglobulin G as shown by immunostaining with F(ab')2 antibodies, as well as complement factors C1, C1q, C3, C3d and C9 in the appropriate central termination areas of the injured sciatic nerve. Results from double labelling immunocytochemistry showed a strong association between immunoglobulin and complement factors on the one hand and reactive microglia on the other. However, some complement immunoreactivity was also found in the neuropil, possibly representing secreted complement. In situ hybridization with an oligonucleotide probe showed a marked increase in C3 messenger RNA, indicating local synthesis of C3 protein. In parallel with activation of complement, there was an increased immunoreactivity for the putative complement inhibitor clusterin, which co-localized with glial fibrillary acidic protein-positive astrocytes. In situ hybridization showed an increased labelling of clusterin messenger RNA. These findings indicate that complement activation and up-regulation of complement inhibitors are prominent central responses to peripheral sensory nerve injury. These responses may therefore be important elements underlying so-called transganglionic degenerative changes in primary sensory axons and terminals.

Motoneuron survival is not affected by the proximo-distal level of axotomy but by the possibility of regenerating axons to gain access to the distal nerve stump

The aim of this study was to examine whether axotomy-induced motoneuron death in adult mammals differ: (1) with the distance between the site of injury and the nerve cell body, and (2) if contact between the transected nerve stumps is established after the injury, compared with cases where contact is prevented. The hypoglossal nerve of adult rats was transected either proximally in the neck (proximal injury) or close to the tongue (distal injury). The nerve stumps were then either deflected from each other in order to prevent axon regeneration into the distal nerve stump, or sutured. Three months later, the extent of nerve cell loss was examined bilaterally in cresyl violet-stained sections of the hypoglossal nucleus. In addition, we examined hypoglossal neuron survival twelve months after a proximal nerve transection with prevented regeneration. Our results show that there was no significant difference in neuronal survival after a proximal nerve transection compared with a distal one, neither if contact between the nerve stumps was established nor if it was prevented. However, contact between the transected nerve stumps increased the likelihood of neuronal survival significantly after both proximally and distally located injury compared to nerve injury with prevented regeneration. There was no significant decrease in nerve cell survival after twelve months with prevented reinnervation compared with survival after three months. These observations indicate that the extent of axotomy-induced motoneuron death in adult mammals does correlate with the proximo-distal level of peripheral injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Deep obstetrical and gynecological infections caused by non-typeable Haemophilus influenzae

Six patients with deep obstetrical and gynecological infections due to non-typeable Haemophilus influenzae are presented. 3 patients had tubo-ovarian abscesses, 2 septic abortions and 1 postpartum sepsis. All our patients with tubo-ovarian abscesses had used intra-uterine contraceptive devices until admission and all had a protracted course of illness. Both patients with septic abortion had a severe course, one of them with disseminated intravascular coagulation demanding treatment in the intensive care unit. The patient with postpartum infection had a milder course. The possibility of infection with H. influenzae and the emergence of beta-lactamase producing strains warrant adequate culture procedures in women with obstetrical and gynecological infections in order to ensure proper treatment.

Clinical pharmacology and the provision of drug information

Clinical pharmacologists have a service role in the provision of drug information to individuals both in hospitals and primary health care. We present here a systematic approach in answering questions in a drug information centre (DIC), and describe the working method and the documentation of the work in a question answer (Q/A) data base. Drugline is a full-text data base offering problem-oriented drug evaluation comparable to a clinical consultation. The drug information is produced in a non-commercial drug information centre sponsored by the national health care sector and the National Corporation of Swedish Pharmacies, and run jointly by clinical pharmacologists and pharmacists. A minor part of Drugline is available in English for online searching, in parallel with Medline at the database host, the Medical Information Centre at the Karolinska Institute Library and Information Centre, and the users represent mainly medical libraries, hospital pharmacies, university clinics, and the pharmaceutical industry. A network of DICs has been organized in Swedish university hospitals with access to Drugline for searching and the storage of questions and answers. This network has the potential for expansion throughout Europe. It offers the unique possibility of complementing drug product information with problem-oriented drug information emerging from cases in the real world of prescribing.

Amplification of DNA by the polymerase chain reaction for the efficient diagnosis of pertussis

The standard diagnostic methods for pertussis have several shortcomings. With the increased knowledge of the Bordetella pertussis genome a specific and conserved DNA sequence, present in about 70-80 copies in each genome, was selected for amplification with the polymerase chain reaction (PCR) technique in order to evaluate its diagnostic potential in children with suspected pertussis. The 400 basepair DNA sequence chosen was present and amplified in all 112 B. pertussis strains and in no other bacterial species examined. The specificity of the amplified material was documented by restriction enzyme cleavage. In nasopharyngeal aspirates a B. pertussis specific PCR product was visualized in 19/25 culture positive and in 5/50 culture negative children. In conclusion the present PCR assay for B. pertussis can be clinically useful and permit a specific diagnosis within 1 day after sampling. Further studies are requested to document its sensitivity, specificity and predictive value for positive and negative results.

Mobiluncus species in bacterial vaginosis: aspects of pathogenesis

Mobiluncus is an anaerobic motile rod associated with bacterial vaginosis. In this work, luminol-enhanced chemiluminescence was used to study the ability of Mobiluncus spp. from the vaginas of women with bacterial vaginosis to induce, in the presence of normal adult serum, oxidative metabolism of polymorphonuclear leukocytes, which is an indirect measure of phagocytic activity. M. curtisii induced a significantly (p less than 0.05) lower response than M. mulieris, which indicates that M. curtisii escapes phagocytosis more easily. Indirect immunofluorescence assays showed IgG antibodies to M. curtisii at significantly (p less than 0.01) higher titres than to M. mulieris in women with bacterial vaginosis. The titres were higher in patients with bacterial vaginosis than in women without vaginosis and healthy men. No antibodies to Mobiluncus spp. of secretory IgA type were found in vaginal washings. These results indicate that M. curtisii is a more virulent species than M. mulieris, and agree with reports of M. curtisii found in postoperative and extragenital infections.