Reviewing the evidence base for the peripheral sensory examination

BACKGROUND

Many students find the peripheral sensory examination confusing. We set out to summarise the evidence base in order to provide guidance on the most useful manoeuvres.

METHODS

We performed a literature review starting with 5 secondary sources, supplemented by a literature search on MEDLINE.

RESULTS

A useful approach to neuropathy is to divide these into large fibre sensory neuropathy (LFSN) in which vibration and proprioception are affected, and small fibre sensory neuropathy (SFSN) in which pain and temperature are affected. Positive sensory symptoms such as burning, electric or sunburn pain point to a SFSN; negative symptoms such as loss of sensation, numbness or deep pain point to a LFSN. If LFSN is suspected, the most reproducible and best studied physical examination is a 10 g monofilament, but vibration sense is also useful. There is much less data on the best physical examination for a SFSN. The most appropriate diagnostic test for SFSN is quantitative sensory testing, whereas for LFSN a nerve conduction study is indicated.

CONCLUSIONS

A modest amount of evidence is available to guide peripheral sensory examination but more research is needed.

An investigation of psycho-social factors associated with the uptake of pre-pregnancy care in Australian women with type 1 and type 2 diabetes

Pre-pregnancy care (PPC) reduces adverse pregnancy outcomes for women with pre-existing diabetes. Yet, despite the compelling case for PPC, participation rates remain poor. The reasons for poor participation are as yet unclear. The aim of this study was to further our understanding of the factors-associated PPC uptake, particularly attitudes and beliefs towards PPC using models of health behaviour: The Health Belief Model, Social Cognitive Theory, and Theory of Reasoned Action. Participants comprised 123 women with type 1 and 2 diabetes attending outpatient clinics for diabetes and pregnancy, who completed questionnaires. Logistic regression analysis indicated that after adjusting for socio-demographic factors, exposure to a greater number of cues was a significant predictor of PPC participation (odds ratio [OR]: 1.93; 95% confidence interval [95% CI]: 1.13-3.28). Other significant predictors of PPC uptake were older age (OR: 1.13; 95% CI: 1.01-1.26) and not having children (OR: 3.93; 95% CI: 1.28-12.06). The findings from this study support initiatives to provide cues to PPC for women with diabetes to enhance PPC uptake. Further, some groups such as younger women as well as women with children may possibly be considered for the focus of more vigorous intervention efforts.

Diabetes Australia position statement. A new language for diabetes: improving communications with and about people with diabetes

Diabetes is the fastest growing chronic condition in Australia, affecting 1.7 million Australians, requiring daily self-care, and known to reduce quantity and quality of life. On average, people with diabetes experience greater emotional distress than those without diabetes. One source of distress can be the language used to refer to diabetes, its management and the person with diabetes. The way verbal and written language is used reflects and shapes people's thoughts, beliefs and behaviours. Language has the power to persuade, change or reinforce beliefs and stereotypes - for better or worse. Words do more than reflect people's reality: they create reality and affect how people view the world and their diabetes. Language needs to engage people with diabetes and support their self-care efforts. Importantly, language that de-motivates or induces fear, guilt or distress needs to be avoided and countered. Diabetes Australia believes optimal communication increases the motivation, health and well-being of people with diabetes, and that careless or negative language can be de-motivating, is often inaccurate, and can be harmful. Diabetes Australia developed this position statement to encourage greater awareness of the language surrounding diabetes and provide recommendations for more careful and positive language use.

318. POLYURIA IN PREGNANCY - CHALLENGES OF DIAGNOSIS!

Increased urinary frequency is a widely experienced symptom in pregnancy; true polyuria is less common and can have a number of causes. It is essential, however that it should be recognized and appropriately investigated, as it may be potentially life threatening to mother and fetus. Diabetes insipidus (DI) is a rare complication of pregnancy. It can be the first presentation of pre-gestational DI, gestational DI or DI associated with acute fatty liver of pregnancy. The latter conditions are illustrated by the following two clinical cases. Osmotic homeostasis can be altered in pregnancy due to resetting of the osmostat and degradation of vasopressin by vasopressinase secreted by the placenta in increasing quantities in the 2nd and 3rd trimesters. Liver failure results in the availability of higher circulating levels of vasopressinase. These cases highlight the difficulties and importance of diagnosis and treatment. Pregnant women often report polyuria during the 3rd trimester. It is important to have a high level of clinical suspicion for the pathological causes, despite the non-specific presentation as underlying conditions can have catastrophic sequelae.

Improving medical student performance in smoking health promotion: effect of a vertically integrated curriculum

The majority of medical schools have curricula that address the health effects of smoking. However, there are many gaps in smoking education, especially in relationship to vertical integration. The authors aimed to determine whether medical students would better address adolescent smoking within a vertically integrated curriculum in comparison with the previous traditional curriculum. They studied two groups of fifth-year students; one group received a specific smoking intervention. Each group consisted of the entire cohort of students within the Child and Adolescent Health rotation of a newly designed medical curriculum. Two groups of students from the previous traditional undergraduate curriculum were available for direct comparison, one of which had received the same teaching on adolescent smoking. An objective structured clinical examination station was used to measure adolescent smoking enquiry. Intervention students in the new curriculum were more likely to enquire about smoking in the objective structured clinical examination than students who did not receive the intervention (p < 0.005). New curriculum students performed better than students from the previous curriculum, whether or not they had received the smoking intervention (p < 0.001). This study suggests that integrated undergraduate teaching can improve student clinical behaviours with regard to opportunistic smoking enquiry in adolescents.

Improving medical student performance in adolescent anti-smoking health promotion

BACKGROUND

We developed a 1-hour teaching seminar for medical students on anti-smoking health promotion for adolescents. We report the development of the programme and a performance-based evaluation.

AIM

To develop a seminar for medical students with the objective of improving medical student inquiry into smoking and the delivery of advice accordingly for adolescent patients in routine consultations.

METHOD

The seminar was developed using principles of adult learning and delivered to a cohort of medical students (intervention group). Participants were Year 5 medical students in their paediatrics term. A comparison group of 58 medical students who did not receive the seminar was studied in the semester prior to the intervention. The primary outcome measure was a change in anti-smoking health promotion practice within an objective structured clinical examination (OSCE), where taking a smoking history and making links between smoking status and health were indicated in a 15-year-old simulated patient (SP) with poorly controlled asthma. This was part of the summative assessment in the paediatrics term.

RESULTS

In the OSCE, 21 of 58 (36%) students in the comparison group asked the asthmatic SP about smoking, compared with 41 of 56 (73%) students in the intervention group (P = 0.0001). In all, 15 (26%) of the comparison group students addressed the patient's smoking, compared with 33 of the 56 (59%) intervention group students (P = 0.0004).

CONCLUSION

A carefully designed seminar addressing adolescent smoking can increase the frequency of smoking inquiry and advice by medical students.

High-dose ifosfamide in combination with etoposide and epirubicin (IVE) in the treatment of relapsed/refractory Hodgkin's disease and non-Hodgkin's lymphoma: a report on toxicity and efficacy

One hundred and seven patients (61 with diffuse large B-cell non-Hodgkin's lymphomas and 46 with Hodgkin's disease) in relapse or following of primary therapy received ifosfamide 3 g/m2 i.v. daily for 3 days in combination with epirubicin 50 mg/m2 i.v. day 1 and etoposide 200 mg/m2 i.v. days 1-3. Of the 46 patients with Hodgkin's disease (28 male, 18 female, and a median age of 28 years) 85% of patients had a response to treatment, with 17 achieving complete remission and 11 good partial remission. Twenty-eight proceeded to autologous bone marrow or peripheral blood stem cell transplantation. Twenty-three patients remain alive in continuous remission with a follow-up of 12-61 months. The median overall survival time for all patients in this group is 36 months. Haematological toxicity, particularly WHO Grade IV neutropenia, occurred in all patients but improved over the three courses of treatment. There was no major non-haematological toxicity. Further trials of this regimen in this clinical situation are indicated. The patients with non-Hodgkin's lymphomas in this study had diffuse large B-cell lymphomas and had only received first-line treatment. Twenty had primarily refractory disease, 15 had only achieved partial remissions (PR), and 26 had developed relapse following primary treatment. The overall response rate was 43%; it was 60% for those who had achieved initial PR, 58% for those in relapse after an initial CR or very good PR following initial therapy, but only 10% for those with primarily refractory disease. Tolerance to the regimen was similar to that observed in treatment of the patients with Hodgkin's disease and many were able to undergo stem cell collection, following mobilization with this regimen. The 2-year overall survival result was 22% for patients with some response to first-line treatment but 0% for primary refractory patients.

Aldose reductase (AC)(n) microsatellite polymorphism and diabetic microvascular complications in Caucasian Type 1 diabetes mellitus

A case-control study to investigate whether the aldose reductase (AC)(n) dinucleotide polymorphism (termed 5'-ALR2 polymorphism) is useful as a genetic marker for risk of microvascular complications among Caucasians Type 1 diabetic patients in Australia is reported. This marker was amplified from patient genomic DNA and then fractionated in 5% formamide-urea gels. A total of nine alleles was observed with Z, Z-2 and Z+2 being the major alleles. The distribution of alleles was comparable in diabetic subjects with diabetes and microvascular complications, diabetes without complications and normal non-diabetic control subjects. Similarly, when the distribution of alleles was examined in the patients subcategorized according to the presence of diabetic nephropathy or diabetic neuropathy, no significant association was observed. While the size of the study makes it impossible to exclude a weak linkage, it is concluded that the 5'-ALR2 polymorphism is not useful as a genetic marker for susceptibility to diabetic microvascular complications in Caucasian Type 1 diabetic patients.

Analysis of CD34 populations in mobilised peripheral blood stem cell harvests and in bone marrow by fluorescent in situ hybridisation for the bcr/abl gene fusion in patients with chronic granulocytic leukaemia

For those patients ineligible for allogeneic bone marrow transplant and who are non-responsive to interferon, autotransplant with peripheral blood stem cells (PBSC) mobilised after intensive chemotherapy, may provide a novel approach to improve prognosis in patients with chronic granulocytic leukaemia. PBSC harvests are assessed for CD34-positive cell numbers, which serve as an indicator of engraftment potential, and are also analysed cytogenetically to ascertain tumour cell contamination. However, a more accurate assessment of PBSC harvest contamination requires investigation of the Philadelphia (Ph) status of the CD34pos population, in which the cells that provide long-term engraftment are contained. In this study, we have analysed these levels in mobilised PBSC and also in bone marrow (BM) harvests, taken several weeks prior to mobilising chemotherapy. Using fluorescent in situ hybridisation for the bcr/abl gene fusion, we have shown that the median number of Ph negative cells in CD34pos isolated populations was 14.95% in BM compared to 79.05% in PBSC harvests and that in all PBSC samples tested, Ph positivity in CD34pos populations was always detectable either by FISH or one round PCR methods. In paired assessments of both PBSC and BM harvests, higher levels of Ph negative CD34pos cells (> or = 14%) isolated from BM harvests, taken prior to intensive chemotherapy, correlated with higher levels of Ph negative CD34pos cells (> or = 78.5%) in PBSC harvests. These data may aid in the selection of patients for whom PBSC harvesting, after mobilisation, is more likely to achieve an autograft product containing predominantly Ph negative CD34pos cells and may exclude those patients for whom the risk, morbidity and expense of stem cell harvesting may have no apparent benefit over a chronic phase BM harvest.

Species-specific repeat units in the intergenic spacer of the ribosomal RNA cistron of Anopheles aquasalis Curry

A genomic DNA library of Anopheles aquasalis Curry was screened for clones that hybridized more intensely to DNA from A. aquasalis than to DNA from A. benarrochi Gabaldon, Cova Garcia, and Lopez, A. konderi Galvao and Damasceno, A. nuneztovari Gabaldon cytotypes A, B, and C, A. oswaldoi (Peryassu), A. rangeli Gabaldon, Cova Garcia, and Lopez, or A. trinkae Faran. Two specific clones (2.5 kilobasepairs [kbp] and 3.0 kbp) from A. aquasalis were isolated. Both A. aquasalis-specific clones were from the intergenic spacer region of the ribosomal RNA (rRNA) cistron. Upon digestion with Rsa I, a 900-bp fragment from the clone AA-1 hybridized specifically to A. aquasalis DNA. Analysis of the DNA sequence of this fragment revealed four tandemly repeated 36-bp units. Three of these repeat units were identical, and the fourth was 94% identical to the others. The DNA sequence of a highly conserved region of these repeats was used to synthesize an oligonucleotide probe specific to A. aquasalis.

A description and morphometric comparison of eggs from eight geographic populations of the South American malaria vector Anopheles (Nyssorhynchus) nuneztovari (Diptera:Culicidae)

The egg of Anopheles nuneztovari is described from scanning electron micrographs of specimens collected from western Venezuela. Morphometric measurements of egg samples from 3 localities in Venezuela, one in Suriname, and 4 in Brazil are compared and relationships analyzed by multivariate statistics. Morphological characters were similar in 2 geographical groups, one Venezuelan and the other Amazonian, that were distinguishable on the basis of differences in size and density of tubercles in the anterior deck region and area of pores in the dorsal plastron. Eggs from western Brazil did not cluster with other Amazonian collections. The distinction of Venezuelan from Amazonian eggs of An. nuneztovari is consistent with chromosomal, ecologic, and molecular evidence for regional genetic differentiation in this species.

Life history correlates of adult size in the malaria vector Anopheles darlingi

Adult dry weights of laboratory-reared Anopheles darlingi were highly correlated with wing lengths, which were used to estimate size variation in natural populations of this species. Significant differences in mean wing lengths of females trapped at baits were detected among collections in the same week at one site, but not between three sites in Brazil and Bolivia. Relatively higher variability of wing lengths, compared to collections of other Anopheles (Nyssorhynchus), and platykurtic size distributions in large, single-night collections suggested that An. darlingi females caught at baits emerged from heterogenous larval habitats. No relationship was detected between parous state and the body size of wild-caught females. Adult males and females of laboratory-reared An. darlingi did not differ in body size. This absence of sexual size dimorphism is rare among mosquitoes and has not been noted previously in the genus Anopheles.

Simulium metallicum cytospecies E larval habitat characterization in the Altamira focus of onchocerciasis, northern Venezuela

Simulium metallicum sibling species E was identified cytotaxonomically from an onchocerciasis focus at Altamira in northern Venezuela. S. metallicum E larvae were sampled monthly from two small mountain streams over a 15-month period (July 1990 to September 1991) and eleven habitat variables were measured at two altitudes. One stream consistently harboured much higher densities of S. metallicum E larvae than the other, with three annual peaks of abundance: during the dry season and at the beginning and end of the rainy season. These peak densities were correlated with high rainfall 4 months previously. Larvae were most abundant on submerged rocks and fallen leaves, in small shallow areas characterized by slow water current, high conductivity and sparse terrestrial vegetation cover. Stream variables which best explained the temporal changes in abundance were water discharge and conductivity. The population dynamics of S. metallicum E appeared to be influenced primarily by interactions between stream discharge and substrate stability. Relevance of these results to vector control with larvicides is discussed.

Outpatient thoracoscopy: a case report and discussion

Thoracoscopy has long been recognized as having significant diagnostic and therapeutic value. We present a new, less invasive method of obtaining good biopsy specimens of pleural based lesions using a single incision and on an outpatient basis. JW, who has a history of Hodgkin's Lymphoma, presents with a suspicious pleural mass adjacent to the AP window and not amenable to percutaneous biopsy. She was admitted to the ambulatory surgery unit and underwent video thoracoscopic biopsy of the lesion through a single 12 mm incision. Surgery time was 25 minutes, and frozen section revealed Hodgkin's lymphoma. No chest tube was inserted, and post-op chest film revealed a small pneumothorax that resolved in 4 hours. The patient was ready for discharge at that time. The technique we used involved placing a standard 10 mm trocar and scope in the midaxillary line with the patient in the lateral decubitus position. Once the scope is in, the trocar is pulled back so that a mediastinal biopsy forcep can be placed alongside the camera through the same hole. The biopsy is taken, and irrigation and cautery instruments can then also be placed and used in a similar manner. Before removing the camera, a prolene pursestring suture is placed around the incision. While the anesthesiologist inflates the lung, the camera is slowly removed, watching all lobes inflate. The pursestring is then tied and the patient awakened. We have performed seven of the above procedures thus far with good results. We feel the following are essential in patient selection for outpatient thoracoscopy: 1) The lesion to be biopsied is pleural based.(ABSTRACT TRUNCATED AT 250 WORDS)

Reproducibility of a meal-based food frequency questionnaire. The influence of format and time interval between questionnaires

OBJECTIVE

To compare the reproducibility and reported level of energy intake obtained using three versions of a meal-based food frequency questionnaire (FFQ) considering, firstly, the influence of FFQ format and, secondly, the influence of time interval between questionnaires.

DESIGN

The study was conducted in two parts. In the first, subjects were randomly allocated to three groups (one for each FFQ) and sent, by mail, the same FFQ to complete on two separate occasions with a time interval of 4-6 weeks. In the second study, the reproducibility of one of the FFQs used in the initial study was compared, after an interval of 3 months, in a further group of people, matched as far as possible for gender, age and socio-economic status of area of residence.

SUBJECTS

The study population was 651 supermarket shoppers from Geelong, a regional centre with a population of 150,000 situated in Victoria, Australia, who had previously responded to an in-store survey about meat purchasing patterns. Of the 651 shoppers, 144 women and nine men (38% of those eligible) in part I and 98 women and two men (45% of those eligible) in part II of the study satisfactorily completed a FFQ on both occasions.

RESULTS

While there were few statistically significant differences in terms of mean nutrient intake and nutrient density between the three FFQ formats, all under-estimated energy intake relative to the minimum estimated energy requirements for a sedentary population. A significant decrease in reported intake of approximately 10% was also observed, regardless of FFQ format used, when the same questionnaire was completed a second time after an interval of 4-6 weeks. In contrast, when the time interval between questionnaires was increased to 3 months, there were few significant differences in intake between the first and second administrations. Moreover those changes in food intake which were significantly different after the longer interval were, in general, consistent with expected seasonal changes in food intake patterns.

CONCLUSION

Under the conditions of our study differences in FFQ format appeared to have less effect on estimates of mean intake than the length of the time interval between questionnaires. Our results suggest that motivation to complete a FFQ is significantly diminished on the second occasion, when the interval between FFQs is only 4-6 weeks and to a lesser extent when it is 3 months. Researchers planning studies which aim to assess short-term changes in food intake by means of a FFQ, for example after an intervention programme, need to be aware of this effect and to determine its magnitude, by assessing the reproducibility of their FFQ over the relevant time-interval prior to the proposed intervention and by including an appropriate non-intervention comparison group in the design of their study if seasonal effects are likely to occur in the course of the study.

Sequence analysis of the ribosomal DNA internal transcribed spacer 2 from populations of Anopheles nuneztovari (Diptera: Culicidae)

Sequence variation of the ribosomal DNA internal transcribed spacer 2 (ITS2) was examined for populations of the malaria vector Anopheles nuneztovari collected in Colombia, Venezuela, Bolivia, Suriname, and Brazil. Mosquitoes from Colombia and Venezuela had identical ITS2 sequences and were distinguished from sequences in other populations by three insertion/deletion events (indels) and by one transversion. The length of the ITS2 was 363-369 bp, and it had a G+C content of 55.3%-55.7%. Variation in the length of the ITS2 between and within populations was due to indels in simple repeats. ITS2 consensus sequences were similar or identical for samples from the following three groups: (1) Colombia, Bolivia, and Venezuela; (2) Suriname and northern Brazil; and (3) eastern and central Brazil. The presence of two different consensus sequences from a single location near Manaus, Brazil, suggests that populations from eastern Brazil and those from Suriname converge in this region of the Amazon Basin. These data show that putative cryptic species of An. nuneztovari are distinguished by very minor differences in DNA sequence of the ITS2 region.

A new cytotype of Anopheles nuneztovari from western Venezuela and Colombia

Cytogenetic analysis of the larval polytene chromosomes of Anopheles nuneztovari from 5 collection sites in Táchira and Zulia states northwest of the Andean Cordillera in western Venezuela and from 2 sites in the Department of Valle, western Colombia, revealed what appears to be a distinctive cytotype informally designated as An. nuneztovari C. Its chromosomes are homosequential with those of An. nuneztovari B from western Venezuela southeast of the Cordillera but differ in the presence of a well-defined chromocenter and unique inversion polymorphisms. The large complex inversion in western Venezuela, 2Lb, is present at a frequency of 0.263 and deviates significantly from Hardy-Weinberg equilibrium in 3 of the 5 sites. Two smaller inversions (2Lc and 2Ld) that are included in 2Lb are present in the Colombian samples at a frequency of 0.300.

Population differentiation of the malaria vector Anopheles aquasalis using mitochondrial DNA

Populations of the malaria vector Anopheles aquasalis from Venezuela, Trinidad, and Brazil were analyzed using restriction enzyme digestion of mitochondrial DNA (mtDNA). The five enzymes surveyed yielded 12 mtDNA haplotypes. Three restriction endonuclease profiles (Bcl I, Eco RI, and Hind III) differentiated the Venezuelan and Trinidadian A. aquasalis from two Brazilian populations. Estimates of mtDNA sequence divergence between the Venezuelan/Trinidadian populations and each Brazilian population (0.023-0.032), as well as divergence between the two Brazilian populations (0.030), were within the range of interspecific distances calculated for members of anopheline species complexes. Ribosomal DNA (rDNA) restriction profiles of the A. aquasalis populations examined were identical.

A polytene chromosome study of four populations of Anopheles aquasalis from Venezuela

Polytene chromosome studies were undertaken to elucidate taxonomic relationships among populations of Anopheles aquasalis and A. emilianus in Venezuela. Four collection sites were chosen: two in Sucre state (Santa Fe and Guayana) where A. aquasalis (considered to be A. emilianus by Gabaldón and Escalante) is presumed to be the major regional vector of Plasmodium vivax; and two in areas where no malaria transmission occurs (Caño Rico, Aragua state, and Puerto Cabello, Carabobo state). The chromosome banding pattern of the four populations was identical and conformed to the standard chromosome map of A. aquasalis from Brazil. These results suggest that the population from Santa Fe and Guayana, considered to be A. emilianus, is conspecific with A. aquasalis. However, its status as a distinct species with a homosequential polytene chromosome banding pattern cannot be ruled out.

A cytogenetic analysis of the polytene chromosomes of Anopheles triannulatus (Diptera: Culicidae) from western Venezuela

The larval polytene chromosomes of Anopheles triannulatus are described for the first time in this report. The population from western Venezuela was chosen arbitrarily as the chromosome standard and is the basis for the photomap presented here. Anopheles trannulatus displays whole-arm associations distinct from other members of the subgenus Nyssorhynchus that have been examined cytogenetically. The association pattern for An. triannulatus is 2R-3R and 2L-3L, rather than the more common 2R-2L and 3R-3L. The possible role of whole-arm translocations in speciation is briefly discussed.

Fecundity, parity, and adult feeding relationships among Nyssorhynchus malaria vectors from Venezuela

Relative to their pre-engorgement weights, nulliparous Anopheles nuneztovari consumed significantly smaller blood meals than A. marajoara, A. triannulatus or A. aquasalis. When females were deprived of sugar before blood feeding, only one-quarter of A. nuneztovari, but more than two-thirds of A. marajoara, A. triannulatus and A. aquasalis matured eggs. Sugar feeding before blood, or two successive blood meals by sugar-deprived females, increased the proportion of nulliparous A. nuneztovari which developed eggs, but not significantly so. Nearly all individuals of nulliparous, sugar-fed A. marajoara, A. triannulatus and A. aquasalis matured eggs after one blood feeding. Among A. nuneztovari, A. marajoara and A. aquasalis that matured some eggs in the laboratory, there were no positive correlations between the number of eggs developed and relative blood meal size. However, blood meals larger than the mean size significantly increased the chance that A. nuneztovari would develop some eggs. Mean fecundities of gravid A. nuneztovari and A. marajoara reared in the laboratory were significantly lower than those of the same species captured at human bait in nature. Post-engorgement access to sugar by A. nuneztovari (captured at human bait) did not influence fecundity, but significantly enhanced survivorship and the proportion of individuals which retained eggs. Release-recapture experiments revealed that relatively small blood meals are typical of A. nuneztovari only during the first gonotrophic cycle. We suggest that multiple blood feeding, seemingly necessary for most A. nuneztovari to develop a first clutch of eggs, may increase the probability of infection with Plasmodium vivax where this mosquito species is a primary vector.

In vivo study of an antimicrobial surgical drape system

We performed a double-blind clinical study to determine the efficacy of nonwoven laparotomy drapes in which 3-(trimethoxysilyl)propyldimethyloctadecyl ammonium chloride, an antimicrobial agent, was chemically bonded to the absorbent reinforcement surrounding the fenestration. The reinforcement portion of the surgical drape that contained the fenestration was segmented into four identical-appearing sections, two on each side of the fenestration. One segment on each side was antimicrobial. The locations of the treated segments were randomly varied. At the end of each operation, test strips were removed. Bacteria were harvested from each segment by mechanical agitation. Bacterial CFU were counted. There were 110 surgical cases in the study, including clean, clean contaminated, and contaminated procedures. Data analysis divided the cases into two distinct groups. Group 1 was composed of 59 cases in which less than 30 total CFU was recovered from the four test samples. The average duration of surgery for this group was 1.8 h. Group 2 was composed of 51 cases in which bacterial recovery was in excess of 30 CFU per procedure (range, 30 to 25,000 bacterial CFU). The average duration of surgery was 3.3 h. Bacterial reduction in the treated strips was 84%. The most common organisms identified on the laparotomy drapes were Staphylococcus epidermidis, S. hominis, and Micrococcus luteus. This study demonstrated that the reinforcement of a laparotomy drape is a reservoir for potential pathogens. It demonstrated that an organosilicon quaternary ammonium antimicrobial agent covalently bonded to the reinforcement reduced the number of potential pathogens surrounding the surgical incision by 84%, independent of the size of the bacterial challenge.

The dexamethasone suppression test in outpatients with primary affective disorder and healthy control subjects

The authors report data on the overnight dexamethasone suppression test (DST) from 64 patients with primary affective disorder (41 unipolar, 17 bipolar-depressed, and 6 bipolar-hypomanic) and 53 healthy control subjects. No difference between the patients and controls was noted in baseline 8:00 a.m. serum cortisol levels or in cortisol levels obtained after the administration of 1 mg of dexamethasone. Sixteen patients and 8 controls had 4:00 p.m. postdexamethasone cortisol levels higher than 5.0 micrograms/dl. The distribution of suppressors and nonsuppressors did not differ significantly between the two groups. Patient nonsuppressors had significantly higher baseline cortisol levels than did patient suppressors (p less than .001). Clinical parameters and family history data did not distinguish patient suppressors from nonsuppressors.

Coated Vicryl synthetic absorbable sutures

An absorbable lublicating coating applied to Vicryl sutures has improved the ease with which the sutures pass through tissue and has made handling and tying better. The coated sutures were found to be safe, strong and secure. No disadvantages were seen as a result of coating the synthetic absorbable Vicryl sutures in the 49 patients studied. Over-all, the coated Vicryl sutures eliminated some of the disadvantages of the braided synthetic absorbable suture without producing new problems.

Hemangiopericytoma. Literature review and clinical presentations

Hemangiopericytomas are soft tissue sarcomas of vascular origin, comprised of pericytes. They have been reported in the extremities, head and neck, back, retroperitoneum, and abdomen. The criteria for the diagnosis and treatment are reviewed. Wide local ablation of the tumor is necessary to prevent local recurrence. Fifty per cent are malignant, although regional node spread is infrequent. Ultrastructural studies are necessary to differentiate hemangiopericytomas from other sarcomas. Long-term follow-up of all cases is essential for optimal clinical management.

Pancreaticoduodenal arterial aneurysms

Experience with four aneurysms of the pancreaticoduodenal artery is reviewed and compared to the reported experience of 19 other cases. In view of the common presentation of such lesions as intra-abdominal hemorrhage preceded by non-specific abdominal pain and other digestive symptoms, it is suggested that angiography perfomed preoperatively or intraoperatively allows definitive diagnosis and leads to specific therapy.

Intramural hematoma of the gastrointestinal tract

Two hundred sixty cases of intestinal intramural hematoma and subsequent bowel obstruction have been reported in the world literature. These cases have been evaluated and seventeen additional cases are reported. Multiple etiologic factors are presented, with trauma and anticoagulant therapy being the most common. Barium x-ray examination is the single most reliable diagnostic study. The mode of therapy for intramural hematoma depends upon thorough evaluation of the patient. Patients on anticoagulant therapy are best treated by observation and cessation of anticoagulants. Should the patient fail to improve or become worse, then surgery may become necessary. When trauma is a factor, prompt operative intervention is indicated.

Revascularization in treatment of mesenteric infarction

This study compares results of primary revascularization with primary intestinal resection in treatment of acute mesenteric artery occlusion in 48 surgical patients. All cases were verified by surgical exploration, angiography or autopsy. Fifteen occlusions were caused by mesenteric thrombosis and 33 by superior mesenteric artery embolization. Primary revascularization was done in 6 of 15 patients with arteriosclerotic mesenteric thrombosis. Total bowel salvage was achieved in 4 patients but no patient with mesenteric thrombosis treated by any method survived long term. Primary embolectomy was done in 11 patients with superior mesenteric artery embolization. Ttoal bowel salvage was achieved in 8 patients. Three of 11 patients died. Primary exploration and/or resection was done in 11 patients; 9 died. All 11 umoperated patients died. A continuation of attempts at mesenteric revascularization is advocated.

Spinal ischemia following abdominal aortic surgery

Serious spinal cord ischemia may follow infrarenal abdominal aortic surgery. Five cases are summarized and added to the 23 previously published cases in order to identify this syndrome, emphasize its importance, and draw attention to the possibility of spontaneous recovery which may occur. The multifactorial complex which comprises each patient's clinical picture clouds a precise and specific cause for paraplegia in these cases. However, neither hypotension, steal phenomena nor emboli are necessary for completion of the syndrome. The relevant spinal cord arterial anatomy indicates that the common anomalies which occur favor development of spinal cord ischemia in the arteriosclerotic population which requires aortic surgery. No means of prevention is possible at this time.

Calciphylaxis: etiology of progressive vascular calcification and gangrene?

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Severe ischemia of the hand

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