Mesenchymal Stem Cells and Regenerative Therapy with Bilateral Gracilis Flaps for Perineal Reconstruction of a Wound Infection in the Setting of Anal Squamous Cell Carcinoma

ABSTRACT

Many patients are affected by HIV/AIDS, and these conditions are highly prevalent worldwide. Patients with HIV/AIDS can experience debilitating wound infections that often require flap reconstruction and become challenging for surgeons to treat. In the past 5 years, mesenchymal stem cells have been tested and used as regenerative therapy to promote the growth of tissues throughout the body because of their ability to successfully promote cellular mitogenesis. To the authors' knowledge, the use of mesenchymal stem cell grafting following necrosis of a myocutaneous gracilis flap (as part of perineal wound reconstruction) has never been reported in the literature.In addition, the use of mesenchymal stem cells and regenerative medicine combined in the setting of squamous cell carcinoma of the anus with prior radiation (along with comorbid AIDS) has not been previously documented.In this report, the authors outline the case of a 60-year-old patient who had a recipient bed (perineum) complication from prior radiation therapy. Complicating the clinical picture, the patient also developed a Pseudomonal organ space infection of the pelvis leading to the failure of a vertical rectus abdominis myocutaneous flap and myocutaneous gracilis flaps. As a result, the patient underwent serial operative debridements for source control, with the application of mesenchymal stem cells, fetal bovine dermis, porcine urinary bladder xenograft, and other regenerative medicine products, achieving a highly successful clinical outcome. A procedural description for future use and replication of this method is provided.

Geriatric All-Terrain Vehicle Trauma: An Unhelmeted and Severely Injured Population

BACKGROUND

All-terrain vehicle (ATV) use is widespread, however, little is known about injury patterns and outcomes in geriatric patients. We hypothesized that geriatric patients would have distinct and more severe injuries than non-geriatric adults after ATV trauma.

METHODS

A retrospective cohort study was performed using the National Trauma Databank comparing non-geriatric (18-64) and geriatric adults (≥65) presenting after ATV trauma at Level 1 and 2 trauma centers from 2011 to 2015. Demographic, admission, and outcomes data were collected, including injury severity score (ISS), abbreviated injury scale (AIS) score, discharge disposition, and mortality. We performed univariate statistical tests between cohorts and multiple logistic regression models to assess for risk factors associated with severe injury (ISS>15) and mortality.

RESULTS

23,568 ATV trauma patients were identified, of whom 1,954 (8.3%) were geriatric. Geriatric patients had higher rates of severe injury(29.2 v 22.5%,p<0.0001), and thoracic (55.2 v 37.8%,p<0.0001) and spine (31.5 v 26.0%,p<0.0001) injuries, but lower rates of abdominal injuries (14.6 v 17.9%,p<0.001) as compared to non-geriatric adults. Geriatric patients had overall lower head injury rates (39.2 v 42.1%,p=0.01), but more severe head injuries (AIS>3) (36.2 vs 30.2%,p<0.001). Helmet use was significantly lower in geriatric patients (12.0 v 22.8%,p<0.0001). On multivariate analysis age increased the odds for both severe injury (OR 1.50, 95% CI 1.31-1.72, p<0.0001) and mortality (OR 5.07, 95% CI 3.42-7.50, p<0.0001).

CONCLUSIONS

While severe injury and mortality after ATV trauma occurred in all adults, geriatric adults suffered distinct injury patterns and were at greater risk for severe injury and mortality.

Lacunar cerebral infarction following endovascular interventions for phlegmasia cerulea dolens

Phlegmasia cerulea dolens is a rare presentation of deep venous thrombus treated with catheter directed thrombolysis and pharmacomechanical thrombectomy. This is the case of a 78-year-old woman who underwent catheter directed thrombolysis to treat phlegmasia cerulea dolens and subsequently developed left-sided hemiplegia and expressive aphasia in the setting of an international normalized ratio of 2.0. Further imaging revealed a lacunar infarct in the right thalamus with a middle cerebral artery distribution. Further workup revealed a patent foramen ovale. We highlight the unexpected enigmatic consequence from multimodal endovascular intervention, the consequence of long-term inferior vena cava filters.

Geriatric Snowmobile Trauma: Longer Courses After Similar Injuries

BACKGROUND

Snowmobiling is a popular activity that leads to geriatric trauma admissions; however, this unique trauma population is not well characterized. We aimed to compare the injury burden and outcomes for geriatric versus nongeriatric adults injured riding snowmobiles.

MATERIALS AND METHODS

A retrospective cohort study was performed using the National Trauma Databank comparing nongeriatric (18-64) and geriatric adults (≥65) presenting after snowmobile-related trauma at level 1 and 2 trauma centers from 2011 to 2015. Demographic, admission, injury, and outcome data were collected and compared. A multivariate logistic regression model assessed for risk factors associated with severe injury (Injury Severity Score >15). Analysis was also performed using chi square, analysis of variance, and Kruskal-Wallis testing.

RESULTS

A total of 2471 adult patients with snowmobile trauma were identified; 122 (4.9%) were geriatric. Rates of severe injury (Injury Severity Score >15) were similar between groups, 27.5% in geriatric patients and 22.5% in nongeriatric adults (P = 0.2). Geriatric patients experienced higher rates of lower extremity injury (50.4 versus 40.3%, P = 0.03), neck injury (4.1 versus 1.4%, P = 0.02), and severe spine injury (20.6 versus 7.0%, P = 0.004). Geriatric patients had longer hospitalizations (5 versus 3 d, P < 0.0001), rates of discharge to a facility (36.8% versus 12%, P < 0.0001), and higher mortality (4.1 versus 0.6%, P < 0.0001). Geriatric age did not independently increase the risk for severe injury.

CONCLUSIONS

Geriatric age was not a significant predictor of severe injury after snowmobile trauma; however, geriatric patients suffered unique injuries, had longer hospitalizations, had higher rates of discharge to a facility, and had higher mortality. Tailored geriatric care may improve outcomes in this unique sport-related trauma population.

Geriatric ATV and snowmobile trauma at a rural level 1 trauma center: A blow to the chest

INTRODUCTION

As the population ages, trauma centers are seeing a significant volume of injured geriatric patients. However, there is limited data on geriatric off-roading incidents. We investigated the injury patterns, severity and outcomes of geriatric versus younger adult all-terrain vehicle (ATV) and snowmobile related trauma with the hypothesis that geriatric patients will have higher mortality and worsened outcomes.

METHODS

The trauma registry at a New England Level 1 trauma center was queried by ICD 9/10 code for adult ATV and/or snowmobile-related trauma from 2011-2019. Data reviewed included demographic, admission, injury, and outcomes data including injury severity score (ISS), abbreviated injury scale (AIS) score, hospital disposition, and mortality. Patients were stratified by age into younger adults (18-64 years old) versus geriatric (65 years and older). Univariate analysis was performed to compare groups.

RESULTS

Over the study period, we identified 390 adult ATV or snowmobile-related trauma patients, of whom 38 were geriatric. The mean ages for the younger adult vs. geriatric cohorts were 41(SD 13) and 73(SD 5), respectively. The majority of patients were male (77%). Compared to younger adults, geriatric patients were more often unhelmeted (66 v 38%, p=0.004) and more likely to present after ATV as opposed to snowmobile trauma (71 v 51%, p=0.028). Geriatric patients more often sustained both any chest trauma (68 v 41%, p=0.003) and severe chest trauma (AIS≥3, 55 v 31%, p=0.022), and more often required tube thoracostomy (26 v 12%, p=0.042). Geriatric patients were also more often discharged to a facility (39 v 14%, p<0.001) compared to younger patients. There were no differences between age cohorts regarding arrival Glasgow coma scale scores, ISS>15, length of stay, ventilator days, complications, or mortality.

CONCLUSIONS

Following ATV or snowmobile-related trauma, geriatric patients were more likely to sustain severe chest trauma and to require additional care upon hospital discharge as compared to younger adults. Primary prevention should focus on encouraging helmet and chest protective clothing use in this geriatric population.

Reducing Radiation and Lowering Costs With a Standardized Care Pathway for Nonoperative Thoracolumbar Fractures

STUDY DESIGN

Retrospective observational study.

OBJECTIVE

There is marked variation in the management of nonoperative thoracolumbar (TL) compression and burst fractures. This was a quality improvement study designed to establish a standardized care pathway for TL fractures treated with bracing, and to then evaluate differences in radiographs, length of stay (LOS), and cost before and after the pathway.

METHODS

A standardized pathway was established for management of nonoperative TL burst and compression fractures (AOSpine classification type A1-A4 fractures). Bracing, radiographs, costs, complications, and LOS before and after pathway adoption were analyzed. Differences between the neurosurgery and orthopedic spine services were compared.

RESULTS

Between 2012 and 2015, 406 nonoperative burst and compression TL fractures were identified. A total of 183 (45.1%) were braced, 60.6% with a custom-made thoracolumbosacral orthosis (TLSO) and 39.4% with an off-the-shelf TLSO. The number of radiographs significantly reduced after initiation of the pathway (3.23 vs 2.63, P = .010). A total of 98.6% of braces were custom-made before the pathway; 69.6% were off-the-shelf after the pathway. The total cost for braced patients after pathway adoption decreased from $10 462.36 to $8928.58 (P = .078). Brace-associated costs were significantly less for off-the-shelf TSLO versus custom TLSO ($1352.41 vs $3719.53, respectively, P < .001). The mean LOS and complication rate did not change significantly following pathway adoption. The orthopedic spine service braced less frequently than the neurosurgery service (40.7% vs 52.2%, P = .023).

CONCLUSIONS

Standardized care pathways can reduce cost and radiation exposure without increasing complication rates in nonoperative management of thoracolumbar compression and burst fractures.

Blood component transfusion and wastage rates in the setting of massive transfusion in three regional trauma centers

BACKGROUND

The purpose of massive transfusion protocols (MTPs) is to provide large quantities of blood products rapidly to exsanguinating patients. The expected rates of blood product transfusion and wastage in this setting have not been defined. This study was undertaken to assess the transfusion and wastage rates for bleeding patients requiring emergency issue of blood components at three American Level I trauma centers.

STUDY DESIGN AND METHODS

Three hospitals participated, all of which are Level I trauma centers that have MTPs in place where uncrossmatched red blood cells (RBCs) can be ordered with or without platelets (PLTs), plasma, and cryoprecipitate. Data on the transfusion, return to blood bank, and wastage rates were recorded on all products issued within 3 hours after MTP activation.

RESULTS

The majority of products were issued to the emergency department and/or operating room at all three institutions (84%-95%). The percentage of RBCs, plasma, and PLTs transfused during MTPs were 39% to 65%, 43% to 66%, and 75% to 100%, respectively. Wastage rates were comparable for RBCs (0%-9%), plasma (0%-7%), and PLTs (0%-7%). Cryoprecipitate had the highest wastage rates at all three sites (7%-33%).

CONCLUSION

A large portion of blood products issued during MTPs are not transfused. Some are wasted due to stringent storage requirements and/or limited shelf lives. The optimum ratio of transfused to returned products in these patients is likely to be determined more by clinical need than by transfusion service policy.

p38 MAPK in cardioprotection - are we there yet?

PKs transfer a phosphate from ATP to the side-chain hydroxyl group of a serine, threonine or tyrosine residue of a substrate protein. This in turn can alter that protein's function; modulating fundamental cellular processes including, metabolism, transcription, growth, division, differentiation, motility and survival. PKs are subdivided into families based on homology. One such group are the stress-activated kinases, which as the name suggests, are activated in response to cellular stresses such as toxins, cytokines, mechanical deformation and osmotic stress. Members include the p38 MAPK family, which is composed of α, β, γ and δ, isoforms which are encoded by separate genes. These kinases transduce extracellular signals and coordinate the cellular responses needed for adaptation and survival. However, in cardiovascular and other disease states, these same systems can trigger maladaptive responses that aggravate, rather than alleviate, the disease. This situation is analogous to adrenergic, angiotensin and aldosterone signalling in heart failure, where inhibition is beneficial despite the importance of these hormones to homeostasis. The question is whether similar benefits could accrue from p38 inhibition? In this review, we will discuss the structure and function of p38, the history of p38 inhibitors and their use in preclinical studies. Finally, we will summarize the results of recent cardiovascular clinical trials with p38 inhibitors.

Abstract 32: Investigating the Autoactivation of p38α Mitogen-Activated Protein Kinase Mediated by Transforming Growth Factor-β-Activated Protein Kinase Binding Protein 1

Activation of p38α MAPK (p38α), by phosphorylation of two residues in the TGY motif of the activation loop, can occur independently of upstream kinases. One such mechanism involves the scaffolding protein Transforming Growth Factor-β-activated protein kinase binding protein 1 (TAB1). Under certain circumstances, such as myocardial ischemia, this activation can aggravate lethal injury. It is one of a few examples of activating autophosphorylation and poses a conundrum. How does an inactive kinase, and therefore with low affinity for ATP, phosphorylate its own activation loop when ATP binding is a prerequisite step for phosphotransfer? The aim of this study was to characterize the TAB1 binding of p38α. The binding characteristics of p38α and TAB1 were determined by Isothermal Titration Calorimetry, followed by the binding of p38α and ATPγS, a slowly hydrolysable form of ATP, in the presence and absence of TAB1. The binding of TAB1 to p38α increased significantly the affinity of p38α for ATP. Following the identification of a key region in TAB1 responsible for p38α binding, a synthetic peptide encompassing this region was used to analyze the biophysical and biological consequences of TAB1 binding. In vitro kinase assays were used to test the biochemical characteristics using a combination of wildtype kinase, kinase dead (K53M) or both in the absence or presence of TAB1(371-416). Using an antibody specific to the dual phosphorylation of the TGY motif as a readout, TAB1 binding to p38α increased p38α autophosphorylation in cis . NMR was employed to map the interaction surfaces between of p38α and TAB1 and to analyze the effect of TAB1-binding on p38α. The residues identified as important for the interaction between TAB1 and p38α were mutated and tested in cell free and biological systems to confirm their role as critical determinants for binding. In conclusion, we have further elucidated a mechanism whereby TAB1 binding to p38α alters the conformation of p38α, increasing its affinity for ATP and thereby facilitating autophosphorylation. We have identified the binding contacts of TAB1 and p38α that may be important in the design of therapeutics enabling selective and circumstance-specific inhibition of p38α activation.

Magnetic resonance angiography in the evaluation of carotid stent patency

As more endovascular interventions are being used in the carotid circulation, including carotid angioplasty and stenting, a reliable imaging modality is needed to follow the results. Currently, duplex ultrasonography, magnetic resonance angiography (MRA), and angiography are the main modalities used. This report presents a case of MRA and duplex ultrasonography providing drastically different images, presenting the clinician with an opportunity to evaluate the various imaging modalities that are used in evaluating carotid stent patency.

Plakoglobin expression and localization in zebrafish embryo development

Plakoglobin (gamma-catenin) and beta-catenin are major components of the adherens junctions and can be localized to the nucleus by activation of the Wnt signalling pathway. In addition, plakoglobin is also found in desmosomes, a vertebrate-specific cell-cell adhesion structure. Plakoglobin expression and localization were examined at the protein level during zebrafish embryonic development by Western blotting and confocal microscopy. Plakoglobin was expressed throughout embryo development at the protein level. Western blotting revealed that embryonic plakoglobin protein content increased between 12- and 24-h post-fertilization (hpf). Confocal microscopy showed that at stages up to 12 hpf, plakoglobin and beta-catenin were co-localized and expressed in both the nucleus and in cell-cell junctions. At 24- and 72-hpf, separate patterns were seen for plakoglobin and beta-catenin. These data indicate that plakoglobin localization in the heart region shifts from adherens junctions to desmosomes during heart chamber development.

Anxiety sensitivity and drug or alcohol use in individuals with anxiety and substance use disorders

Anxiety sensitivity (AS) has been linked to both pathological anxiety and substance use problems. We evaluated relations between AS and substance use situations among individuals with substance use disorders (SUDs) and concurrent DSM-IV anxiety disorders. We predicted that AS would be most strongly associated with substance use in situations involving negative emotions and interpersonal conflict in substance abusers with anxiety disorders. This group was compared to substance abusers with concurrent mood disorders and substance abusers without other disorders (N=88). AS was positively related to negative emotion situations substance use for substance abusers with anxiety disorders and for substance abusers without other disorders. Contrary to predictions, significant differences between these groups were not found. The relationship between AS and negative emotion situations substance use remained after controlling trait anxiety in a combined group (anxiety disorders and substance abuse only groups). AS did not predict substance use for participants with concurrent mood disorders. Identification of factors that place anxious patients at risk for substance use problems will have implications for treatment and for the prevention of this form of maladaptive coping.

Carcinoma of the ampulla of Vater: prognostic factors after curative surgery: a series of 45 cases

BACKGROUND

Some adjuvant or neoadjuvant therapy could be important for patients operated on for tumours of the ampulla of Vater, especially for those having a higher risk of recurrence.

AIM

To evaluate prognostic factors after curative surgery based on a series of 45 cases of malignant tumours of the Oddi sphincter.

PATIENTS

From 1970 to 1992, a curative resection was performed in 45 patients (age 62.8 (SD 10.1) years) with adenocarcinoma of the ampulla. Surgical procedures included pancreatoduodenectomy (n = 42) and resection of the ampulla (n = 3). Actuarial survival was 44 (SD 9)% at five years.

METHODS

Various prognostic variables were studied: clinical manifestations, macroscopic aspect, differentiation, noninvasive adenomatous component, mucin histochemistry, immunohistochemistry (CEA, CA19.9, p53, Ki67), and accepted classifications (Blumgart and Kennedy, Martin, Yamaguchi and Enjoji, Talbot et al, pTNM).

RESULTS

Variables with prognostic power, in order of importance were: Classification of Talbot et al; CA19.9; pTNM; sialomucins; classification of Yamaguchi and Ejoji; Martin classification; sulphomucins; non-invasive adenomatous component (positive > negative); jaundice; tumour localisation.

CONCLUSIONS

This series confirmed the prognostic power of former classifications and showed the prognostic power of other variables (mucin, non-invasive adenomatous component, CA19.9).

Approaches to rationing drugs in hospitals. An Australian perspective

The increasing need to consider rationing strategies within the healthcare environment is being driven by pressures such as the development of new medical technologies, the aging population, patient awareness and expectations, healthcare professionals' appetite for new treatments, and government restrictions on healthcare costs. Solutions to these pressures will need to be sought urgently to avoid a situation in which quality of healthcare is affordable only for the wealthy. The fundamental principles of equity and fairness will need to be applied universally if the solutions are to be accepted by the community, patients and practitioners. There are several measures that a hospital must have in place before the concept of drug rationing can be contemplated. The approach essentially involves ensuring rational drug approval processes based on critical review of the available data, coupled with ongoing education and audit. Thus, accurate information and clinical budgeting systems, processes which encourage and ensure structural and technical efficiencies within the drug use sequence and an effective Drug and Therapeutics committee are required to facilitate this approach. To assist with its overriding goals of the quality use of medicines and optimal patient care, the Drug and Therapeutics committee needs to implement an effective formulary system, obtain detailed guidelines governing drug use within the institution, conduct an ongoing drug utilisation review programme, and provide education and training. The move to consider allocative decision making (rationing) will become increasingly necessary as limits on structural and technical efficiency measures are reached. An institution will then need to decide whether to treat a particular group of patients, or provide a certain form of treatment. Improved methods for community consultation need to be explored and there must be a partnership between the health provider and the consumer in enunciating the existence of scarcity, determining priorities and ensuring that ethics and equity are not abandoned through this process.

[Contribution of computers and telepathology in cancerologic pathology]

The histologic or cytologic diagnosis of a tumoral lesion may be sometimes very difficult to do even for a senior pathologist. Nevertheless, it is necessary to recognize a malignant process with reliability and security. The usual way to solve some difficult problems is firstly to search documentations in books or atlas and then to discuss the slides in common. Sometimes it is necessary to dispatch the original documents to a national or international expert. Now computers are used in any private or public department of Pathology. Some new informatics developments allow to send good digitized pictures to an expert and to discuss with him. It is also possible to elaborate a data base of digitized images which can be edited on CD-Rom. We describe the development and the use of these technics in France and elsewhere. It seems that they could have an increasing role for quality assurance in tumoral pathology.

How can hospitals ration drugs? Drug rationing in a teaching hospital: a method to assign priorities. Drug Committee of the Royal Adelaide Hospital

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Family history of alcoholism, alcohol use disorders and the five-factor model of personality

This study examines NEO-FFI correlates of risk for alcoholism, alcohol use disorders and alcoholism subtyping dimensions in a mixed-gender sample of 468 young adults (mean age = 21.3) presumed to be at high risk (n = 239) or low risk (n = 229) for alcoholism on the basis of a family history of paternal alcoholism. The NEO-FFI is a brief personality inventory measuring each of the key dimensions of the five-factor model of personality (FFMP), a comprehensive, empirically-derived model of personality structure. Familial risk for alcoholism was positively associated with openness and negatively associated with agreeableness and conscientiousness. Alcohol use disorders were positively associated with neuroticism and negatively associated with aggreeableness and conscientiousness. With the exceptions of alcoholism subtyped by comorbid antisocial personality disorder and by familial alcoholism, all of the alcoholic subtypes examined were related to at least one of the five dimensions. We conclude that the FFMP holds promise for studying personality traits in alcohol use disorders and in bringing a unifying perspective to research and clinical work in this area.

Beyond Section 504: satisfaction and empowerment of students with disabilities in higher education

College and university students with disabilities were surveyed to determine their levels of satisfaction with accessibility, special services, and accommodations at their schools. In addition, students were requested to identify barriers to postsecondary education, improvements in services, and other concerns. Respondents generally expressed satisfaction with the services that they had received. However, the majority indicated that they had encountered barriers to their education, including a lack of understanding and cooperation from administrators, faculty, staff, and other students; lack of adaptive aids and other resources; and inaccessibility of buildings and grounds. Recommendations were made for improving the delivery of services and self-advocacy of students with disabilities.

Improving resources for foster care

The number of foster children and their psychological and medical morbidity are growing. To gain insight into how to recruit and retain foster homes, characteristics of 64 foster families were determined by interview. Foster parents had low-to-moderate incomes, were approaching middle age, had underutilized home space, and wanted more children. Most enjoyed foster care and planned to continue. Twenty-three percent of the 64 had half of all foster children in the study in their homes at interview and had cared for seven times as many children in the past, including 66% of all the teens and 83% of all the handicapped children who had been in the 64 homes. These "high providers" functioned like group homes for mentally handicapped individuals. Adapting the group-home concept to foster homes could improve care, especially for children with special needs.

The Department of Defense Civilian External Peer Review Program: an interim report

During a 2-year period (December 1987-December 1989), 165 Department of Defense (DoD) military hospitals world-wide provided 71,800 cases with 83,197 reviews for quality of care evaluations by the Civilian External Peer Review Program (CEPRP). The majority (78,246 of 79,896) of completed peer review determinations (97.9%) generated agreement with care and documentation. It is concluded that health care in military treatment facilities is of high quality, meeting and generally exceeding accepted standards of care. It is also concluded that the DoD CEPRP offers conceptual and practical experience to guide the further evolution and integration of clinical peer review and quality improvement activities.

Prevalence of DSM-III-R disorders among nonclinical compulsive checkers and noncheckers in a college student sample

The prevalence of lifetime DSM-III-R disorders was assessed in a sample of 100 college students who were classified as compulsive checkers (n = 50) or noncheckers (n = 50) on the basis of their responses to the Checking subscale of the Maudsley Obsessional-Compulsive Inventory (MOCI). DSM-III-R disorders were assessed on the basis of responses to the Diagnostic Interview Schedule, Version III Revised (DIS-III-R), administered by trained, lay interviewers, blind to Ss' checking status. Checkers, compared to noncheckers, were significantly more likely to meet lifetime diagnostic criteria for Major Depressive Episode, Drug Abuse/Dependence, and Social Phobia. Analysis of a subsample (n = 74) selected on the basis of the consistency of responses to the MOCI across two administrations replicated the above effects, with two exceptions: (1) checkers were more likely to meet criteria for Obsessive Compulsive Disorder than were noncheckers, and (2) for males, but not females, Simple Phobia was more prevalent among checkers than among noncheckers. These findings extend our previous work by demonstrating that 'nonclinical' checking behavior is associated with a broad range of psychological syndromes and may, in fact, be more strongly associated with other disorders than it is with Obsessive Compulsive Disorder in a nonclinical sample.

Drug utilization review in a teaching hospital: experience with vancomycin

A prospective, two-phase, drug utilization review (DUR) was performed at the Royal Adelaide Hospital (RAH) to determine the extent and pattern of vancomycin use. For all patients commencing oral or parenteral vancomycin, treatment indication, route of administration, duration of therapy, results of culture and sensitivity tests, adverse drug reactions and results of therapeutic drug level monitoring were recorded. Vancomycin courses were classified as being for therapy or prophylaxis and compared with predetermined audit criteria to assess appropriateness of use. During the 8 week initial phase, data on 62 treatment courses in 59 patients were recorded, 50% for therapy and 50% for prophylaxis. Sixty four percent were classified as inappropriate, occurring in 32% of therapeutic courses and 97% of those for prophylaxis. During the 10 week re-evaluation, conducted 10 months later, data for 43 treatment courses in 43 patients were reviewed, 42% for therapy and 58% for prophylaxis. Sixty five percent were inappropriate occurring in 17% of therapeutic courses and 100% of the prophylactic courses. When compared with the initial phase, the re-evaluation demonstrated a decrease in the empirical use of vancomycin in the combination treatment of neutropaenic fever and also in the duration of vancomycin use for surgical prophylaxis. During both study phases, criteria contraventions were mostly due to inappropriate indication or duration of therapy. The cost of inappropriate vancomycin use was reduced by over 50% between survey phases, from $Aus11,500 or 55% of total vancomycin cost during the initial phase to $Aus3,600 or 25.7% during the re-evaluation. The most effective of the remedial strategies implemented after the initial phase was direct consultation with prescriber groups.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparative review of developmental screening tests

Public Law 99-457 amends the Education of the Handicapped Act to include services for children from birth through 3 years. Inasmuch as detection and referral of children with developmental delays continues to reside largely with pediatricians and other health care professionals, developmental screening, using standardized tests, is increasingly important. To help physicians select from the array of instruments, 19 different screening tests were administered by a pediatrician and rated by a panel of pediatricians and a special educator. While the panel found few tests that fit within the time constraints of pediatric practice, several tests approached standards for educational and psychologic tests. These included the Battelle Developmental Inventory Screening Test, Infant Monitoring System, Developmental Indicators for Assessment of Learning-Revised, Screening Children for Related Early Educational Needs, and the Developmental Profile II.

Apolipoprotein AI is a serum and tissue marker of liver fibrosis in alcoholic patients

The aim of this study was to assess the specific correlation of apolipoprotein-AI to hepatic fibrosis in alcoholic patients. Four hundred eighty two patients were prospectively included with serum measurement of apolipoprotein-AI within 10 days before liver biopsy. Pathologic features were semiquantitatively assessed by two observers. In 28 patients liver biopsy was used for histomorphometric assessment of fibrosis and immunohistochemical labeling of apolipoprotein-AI. Serum apolipoprotein-AI was negatively correlated to semiquantitative score of fibrosis (r = -0.50; p less than 0.001), independently of the scores of steatosis and alcoholic hepatitis (r = -0.44; p less than 0.001) and of the value of serum albumin, bilirubin, and prothrombin time (r = -0.22; p less than 0.001) and independently of the nutritional parameters (r = -0.29; p less than 0.009). The mean value of apolipoprotein-AI decreased according to the grade of fibrosis from 220 +/- 6 mg/dl (mean +/- SEM) to 110 +/- 8 mg/dl. Serum apolipoprotein-AI was negatively correlated to the percentage of fibrosis (r = -0.70; p less than 0.001) in the biopsies morphometrically assessed. The labeling was superimposed to the extracellular matrix. In conclusion, this study shows that decrease of apolipoprotein-AI is a serum and tissue marker of liver fibrosis independently of steatosis, alcoholic hepatitis, liver function tests, and nutritional parameters.

Perisinusoidal cells (Ito-cells) enlargement in a family with myotonic dystrophy

Two cases are reported, a daughter and her mother who both have myotonic dystrophy with abnormalities of liver function tests and an important perisinusoidal cell enlargement without other pathologic features. In both cases, the myotonic dystrophy was clinically obvious and confirmed by electromyography. No other causes of perisinusoidal cell enlargement were found including vitamin A intake, psoriasis, viral disease or alcoholism. These observations suggest a genetic linkage and that serum test abnormalities could be associated with a perisinusoidal cell change.

Analysis of mucosal bladder leucocyte subpopulations in patients treated with intravesical Bacillus Calmette-Guerin

Immunohistochemical techniques were used to investigate leucocyte subpopulations in the bladders of patients with superficial transitional cell carcinoma treated with BCG Pasteur. Leucocyte subsets were enumerated with a panel of monoclonal antibodies which included CD3, CD4, CD8, TQ1, Leu7, CD15, HLA-DR, CD25, CD22. We demonstrated in the bladders of patients treated with BCG a particular lymphocyte population; the major subset was an inducer (CD4+, TQ1-) which was activated (CD25+, HLA-DR+) and associated with polymorphonuclear eosinophils. There was neither inducer of suppression nor major cytotoxic/suppressive subsets. CD8+ and NK cells could not be the primary mediators of BCG activity. These data supported the hypothesis of a helper T lymphocyte activity associated with lymphokine production and activation of effector killer cells.

Parental administration of chemical agents: a cause of apparent life-threatening events

Nine infants with apparent life-threatening events that occurred as a result of poisoning by a caretaker are described. These episodes were characterized by apnea plus some combination of color change, choking or gagging, and abnormal muscle tone. Five of the infants responded to vigorous stimulation, and four required cardiopulmonary resuscitation. Most poisonings (seven infants) were detected by a urine drug screen. Medications detected included acetaminophen, amphetamine, benzodiazepines (two infants), cocaine, codeine, meperidine (two infants), Methadone, phenobarbital, and phenothiazines (three infants). Four infants received two or more drugs. Most perpetrators of the poisonings were mothers (seven) and five of the parents admitted administering the various agents. Reasons for the poisonings included an apparent attempt to harm an infant, the need to sedate a fussy infant, or a gross misunderstanding of the potential risk of various agents to infants. Because no history of drug administration was elicited at the time of hospital admission, six infants might have been discharged with a diagnosis of apnea of infancy had not an attempt been made to investigate the possibility of poisoning. These cases suggest that poisoning by a caretaker should be added to the differential diagnosis of any infant brought to medical attention because of an apparent life-threatening event and that urine drug screening should be considered in the evaluation.

Observer variation in assessment of liver biopsies of alcoholic patients

The aim was to construct a questionnaire analyzing pathological features possibly present in alcoholic liver disease, to assess its interobserver variation and to determine the influence of technical data on this variation. A total of 764 inpatients drinking 90 g (median) of pure alcohol per day for 25 years was observed; 402 patients were excluded because of associated nonalcoholic disease, refusal or contraindication to biopsy, leaving 362 patients included. Two pathologists independently analyzed each biopsy and completed a questionnaire including 41 items. Coefficient of concordance between observers was evaluated with the kappa statistic (k). The prevalence of 14 lesions was low, equal to or under 10%, leading to a nonsignificant concordance. For the 27 remaining features, two had an almost perfect degree of concordance (k greater than 0.81): presence of hepatocellular carcinoma and cirrhosis. Three had a substantial coefficient of concordance (k greater than 0.61): fibrous septa, size of cirrhotic nodules, and liver cell regeneration. Nine had a moderate (k greater than 0.41), 11 a fair (k greater than 0.21), and two a slight (k less than 0.21) coefficient of concordance. In terms of final diagnosis of alcoholic liver disease the concordance was substantial for cirrhosis with acute alcoholic hepatitis (k = 0.77), cirrhosis without alcoholic hepatitis (k = 0.75), acute alcoholic hepatitis without cirrhosis (k = 0.65) and normal liver (k = 0.64). Concordance was moderate for steatosis (k = 0.47) and slight for fibrosis alone (k = 0.16).(ABSTRACT TRUNCATED AT 250 WORDS)

Histochemical study of mucosubstances in carcinoma of gastric remnant

Twenty patients with carcinoma of the gastric remnant after surgery for benign disease have been studied. The histologic and histochemical data on gastric mucosa surrounding the carcinoma have been compared with data from 60 biopsy samples taken from gastric stumps without carcinoma in an age-and sex-matched group. There was a high incidence of intestinal metaplasia in the gastric stumps (24 of 60); it was even higher in the cases with a carcinoma (17 of 18). Intestinal metaplasia Type III, which is closely related to the carcinoma in a stomach not surgically treated, was rare in cases of cancer in the gastric stump (1 in 18). This finding is correlated to the high frequency of the diffuse type of carcinomas that occur in the gastric stump (15 of 20), which are rarely associated with intestinal metaplasia. Therefore, identifying intestinal metaplasia types does not always point to the fact that affected patients will also be at high risk for cancer in their gastric remnant.

[Lesions of the area of Oddi's sphincter: incidence and association with biliary and pancreatic lesions in a series of 109 autopsies]

One hundred and nine successive post mortem examinations have been performed with a peculiar attention to the gross and microscopic features of the sphincter of Oddi. Biliary lesions were present in 24 cases and pancreatic lesions in 7 cases. According to previous histologic descriptions, a group of 18 pathologic sphincters of Oddi was selected. Biliary lesions were not more common in this group (28 p. 100) than in the group with a normal sphincter of Oddi (21 p. 100) and inversely, there were no more lesions of the sphincter of Oddi in the group with biliary lesions (21 p. 100) than in the group without biliary lesions (15 p. 100). Chronic pancreatitis was more frequently associated with an abnormal sphincter of Oddi, but in these cases, another associated disease could explain pancreatitis (alcoholism, hemochromatosis). Pathologic lesions of the sphincter of Oddi are frequent and usually latent. These features are not simple anatomic variations because five cases were undoubtedly pathologic with an important thickening of the sphincter and a fibro-adenomatosic pattern. This study shows that sclerosing odditis does exist but is rare.

Comparative study of automated morphometric and semiquantitative estimations of alcoholic liver steatosis

Needle biopsy of the liver is of great value in appreciating the intensity, type and topography of the steatosis commonly observed during chronic alcoholic diseases. The usual semiquantitative optical analysis is very inaccurate and depends on the subjectivity and training of the pathologist. We therefore performed an automated analysis of liver steatosis using a QTM 720 image analyzer connected to a PDP 11/34 minicomputer. Visual control of the results of the automated analysis showed it to give good results: 94% of the droplets were detected and only 10% of the patterns automatically selected were not droplets. Eight normal biopsies and 37 biopsies showing alcoholic liver steatosis were analyzed. The automated morphometric analysis calculated the mean density (percentage) of steatosis and the size distribution of the droplets. Statistical comparison of these results with those of the semiquantitative optical analysis performed independently by two pathologists showed a significant correlation between their calculations of the density/degree of steatosis but significant differences for their evaluation of the type of steatosis. The pathologists constantly overestimated the ratio of macrodroplets to microdroplets.

Continuing education: a quality assurance approach

In the arena of accountability measures in health care recertification mechanisms are being evaluated for their cost-effectiveness in occupational therapy. The use of continuing education as one recertification option raises concern about the efficacy of educational activities. One measure of program quality is the continuing education unit. Criteria for its award are delineated. Several methods for implementing the measurement of educational activities in occupational therapy are examined.

Night terrors. Clinical characteristics and personality patterns

The development and clinical course of night terrors and the personality patterns of patients with this disorder were evaluated in 40 adults who had a current complaint of night terrors. Compared with a group of adult sleepwalkers, the patients with night terrors had a later age of onset for their disorder, a higher frequency of events, and an earlier time of night for the occurrence of episodes. Both groups had high levels of psychopathology, with higher values for the night terror group. This sleepwalkers showed active, outwardly directed behavioral patterns, whereas the night terror patients showed an inhibition of outward expressions of aggression and a predominance of anxiety, depression, tendencies obsessive-compulsive/, and phobicness. Although night terrors and sleepwalking in childhood seem to be related primarily to genetic and developmental factors, their persistence and especially their onset in adulthood are found to be related more to psychological factors.