Managing opioids and mitigating opioid risks in patients with cancer: An environmental scan of the attitudes, confidence, and practices of ambulatory, community and hospital pharmacists practicing in Canada

INTRODUCTION

Canada is in the midst of an overdose crisis. The use of prescription opioids in Canada has increased steadily over the past two decades, with stark increases in opioid-induced respiratory depression and related deaths. Opioids are the mainstay of treatment for cancer-related pain. Patients with cancer are not immune to the risks associated with opioid use but are underrepresented in available literature outlining risk mitigation strategies. Pharmacists are ideally placed to employ opioid risk mitigation practices to support safe and effective opioid use for patients with cancer-related pain. However, the current attitudes, confidence, and safety practices of pharmacists around how to best support these patients are not known.

METHODS

This study was a descriptive environmental scan of pharmacists who provide direct patient care in Canada. An electronic questionnaire was built using the web based Opinio software. It was distributed via email by several provincial and national pharmacy organizations and online platforms. The questionnaire consisted of Likert-scale and open-ended questions and was open to participants for a 6-week period from February 12th to March 23rd, 2020. Analysis was conducted using descriptive statistics and qualitative content analysis.

RESULTS

Eighty-one responses from pharmacists in nine provinces were included in the analysis. Respondents endorsed limited and varied practices when caring for patients receiving opioids for cancer-related pain. Further, they demonstrated wide ranging confidence and attitudes regarding opioid risk mitigation practices and beliefs. Less than 50% of pharmacists were aware of resources available for their patients with non-medical opioid use, and/or patients at high risk of opioid-induced respiratory depression. Education, resources, and communication were the most commonly reported perceived facilitators and barriers to resource use.

CONCLUSIONS

Pharmacists in Canada report employing opioid risk mitigation practices with low and varied frequency when caring for patients receiving opioids for cancer-related pain. They endorsed varied confidence and limited awareness of available provider and patient resources. These findings may help inform the development of new education models and evidence-based guidelines. New education models and evidence-based guidelines will support pharmacists in their pharmaceutical care of this vulnerable patient population, ultimately aiming to improve patient outcomes.

Medical interns in district health services: an evaluation of the new family medicine rotation in the Western Cape of South Africa

BACKGROUND

In 2021, South Africa introduced a 6-month internship rotation in family medicine, in the second year of a 2-year internship programme for newly qualified doctors. This was a major change from the previous 3-months training in family medicine, and expanded the training platform to smaller district hospitals and primary health care (PHC) facilities, many of which had never had interns. The medical disciplines in South Africa needed to know if this change in the internship programme was worthwhile and successful. The aim of this study was to assess the new family medicine rotation for medical interns at district health facilities in the Western Cape Province.

METHODS

Descriptive exploratory qualitative research included six intern programmes across the province. Purposeful sampling identified a heterogeneous group with maximum variation in experience. Overall, eight interns, four managers, four supervisors and four intern curators were included. Individual semi-structured interviews were audio-recorded and the transcripts were thematically analysed using the framework method and Atlas-ti software.

RESULTS

Four major themes emerged around the varied structure and organisational characteristics of the rotations, the orientation and arrival of interns, their learning during the rotation, and impact on health services. A programme theory was developed that defined the key inputs (i.e. infrastructure, communication, orientation, preparation, prior learning and guidelines), processes (i.e. model of the rotation, clinical training and supervision, clinical teaching), outputs (i.e. more independent decision making, approach to undifferentiated problems, approach to chronic care and continuity, development of procedural skills, approach to sequential coordination of care and referrals, working in a multidisciplinary team and inter-professional learning, integration of multiple competencies, as well as becoming more person and community orientated).

CONCLUSIONS

The new rotation in family medicine was positively experienced by most interns, supervisors and managers. It should lead to improved quality of care, better preparation for obligatory community service, and an increased likelihood of considering a career in district level health services. This study will form part of an exploratory sequential mixed methods study that incorporates the key issues into a questionnaire for a descriptive survey of all interns in a subsequent study.

362 The Scarlet Pimpernel: A Case of Polyarteritis Nodosa Presenting as a Left Hepatic Artery Aneurysm

A 54-year-old female presented to a secondary care hospital with right upper quadrant pain, headache, and persistent dysuria after empirical antibiotic treatment for a urinary tract infection (UTI). Her brother had died under the age of 50 from aneurysmal disease associated with Polyarteritis nodosa (PAN). Urinalysis demonstrated erythrocytes, leucocytes, and nitrites. Her CRP was 428mg/L and ESR 102 mm/hr. CT of the abdomen and pelvis showed reduced attenuation within both kidneys, and she was treated as acute bilateral pyelonephritis with IV antibiotics. Her abdominal pain changed, she described a “pop” in her right hypochondrium, and she developed a new visual disturbance, despite normalisation of her inflammatory markers. This warranted a repeat CT scan which showed an occlusion of the left hepatic artery with surrounding inflammation and an 8mm aneurysm proximally. MRI and CT venogram of the head was unremarkable. PAN was diagnosed on remote consultation with a tertiary care hospital. It is a necrosing vasculitis affecting small to medium sized arteries with aneurysmal dilatation. There is no genetic cause known, though familial cases have been described. The patient was started on treatment dose Dalteparin and transferred to a tertiary hospital. Selective embolisation of the hepatic artery aneurysm was not undertaken, but she was treated with glucocorticoids and cyclophosphamide. This case highlights a rare condition presenting similarly to a treatment refractory UTI requiring multidisciplinary patient care and the need for repeat imaging following clinical deterioration/change.

Clinical Pharmacy Services in Ambulatory Oncology: An Environmental Scan of the Canadian Practice Landscape

Background: Canadian clinical pharmacy key performance indicators (cpKPIs) have been developed for inpatient hospital practice but are not established for ambulatory oncology. This study represents the first step in developing cpKPIs for ambulatory oncology. Objectives: To describe the current landscape of pharmacy services in ambulatory oncology in Canada and to identify perspectives related to the development and implementation of cpKPIs in this practice setting. Methods: In this national cross-sectional study, a web-based questionnaire was distributed to pharmacists working in ambulatory oncology settings. Potential participants who self-identified as pharmacists practising in an ambulatory oncology setting were eligible. Survey questions focused on participants’ demographic characteristics, oncology pharmacy services provided, metrics captured, and pharmacists’ perceptions of cpKPIs. All data were analyzed using descriptive statistics. Results: A total of 44 responses were received, with most respondents practising in community hospitals in British Columbia, Ontario, and Atlantic Canada. The services most commonly provided were chemotherapy order verification, laboratory monitoring, identification and resolution of drug therapy problems, and counselling on anticancer medications. Twenty-six of the 44 respondents (59%) indicated that performance metrics or patient outcomes were tracked at their respective institutions, with none being universally captured. Overall, 43 (98%) of the respondents favoured the development of cpKPIs for ambulatory oncology practice. Conclusions: Despite growing patient care needs in ambulatory oncology, there is significant heterogeneity in the scope of pharmacy services offered and the outcomes used to qualify their impact within this setting across Canada. This study demonstrates a clear need for national consensus cpKPIs to inform pharmacy resource utilization and patient-centred quality improvement initiatives. RÉSUMÉ  Contexte : Des indicateurs clés de performance de la pharmacie clinique canadienne (cpKPI) ont été élaborés pour la pratique hospitalière en milieu hospitalier, mais n’ont pas été définis pour l’oncologie ambulatoire. Cette étude constitue la première étape de l’élaboration de cpKPI pour l’oncologie ambulatoire. Objectifs : Décrire le paysage actuel des services pharmaceutiques en oncologie ambulatoire au Canada et cerner les perspectives liées au développement et à la réalisation de cpKPI dans ce contexte de pratique. Méthodes : Dans cette étude transversale nationale, un questionnaire en ligne a été distribué aux pharmaciens qui travaillent en oncologie ambulatoire. Les participants potentiels qui se sont identifiés comme des pharmaciens exerçant dans ce contexte étaient autorisés à participer. Les questions de l’étude portaient sur les caractéristiques démographiques des participants, les services de pharmacie offerts en oncologie, les paramètres saisis et les perceptions des pharmaciens à l’égard des cpKPI. Toutes les données ont été analysées à l’aide de statistiques descriptives. Résultats : Au total, 44 réponses ont été reçues, la plupart des répondants exerçant dans des hôpitaux communautaires de la Colombie-Britannique, de l’Ontario et du Canada atlantique. Les services les plus couramment fournis étaient : la vérification des ordonnances de chimiothérapie, la surveillance en laboratoire, l’identification et la résolution des problèmes de pharmacothérapie et les conseils portant sur les médicaments anticancéreux. Vingt-six des 44 répondants (59 %) ont indiqué que les indicateurs de performance ou les résultats pour les patients faisaient l’objet d’un suivi dans leurs établissements respectifs, bien qu’aucun ne soit universellement saisi. Dans l’ensemble, 43 répondants (98 %) étaient favorables à l’élaboration de cpKPI pour la pratique de l’oncologie ambulatoire. Conclusions : Malgré les besoins croissants des patients en oncologie ambulatoire, la portée des services pharmaceutiques offerts et les résultats utilisés pour qualifier leur effet dans ce contexte au Canada sont fortement hétérogènes. Cette étude démontre un besoin évident de consensus portant sur les cpKPI à l’échelle nationale pour éclairer l’utilisation des ressources pharmaceutiques et les initiatives d’amélioration de la qualité centrées sur le patient.

Health Care Professionals’ Perceptions of the Role of the Clinical Pharmacist and Expanded Pharmacist Coverage in Critical Care

Background: During the first wave of the COVID-19 pandemic, coverage by critical care pharmacists (CCPs) was expanded in 2 medical–surgical intensive care units at the Queen Elizabeth II Health Sciences Centre, in Halifax, Nova Scotia, from 8 hours per day, 5 days per week, excluding holidays, to 8 hours per day, 7 days per week, including holidays.  Objectives: To describe health care professionals’ opinions about and perceived impacts of the expanded CCP coverage on patient care, as well as their opinions about the role of the CCP as a member of the critical care team.  Methods: An electronic 22-item survey was distributed to critical care health care professionals to capture opinions and perceived impacts of expanded CCP coverage. The perceived importance of 25 evidence-informed CCP activities was assessed using a 5-point Likert scale.  Results: Thirty-eight complete responses were included (15% response rate, based on distribution of the survey to 249 health care professionals). Most respondents agreed or strongly agreed with the following statements: CCPs are integral members of the critical care team (34/38 [89%]), CCPs play an important role in improving patient outcomes (34/38 [89%]), the presence of CCPs on the unit and on patient care rounds allows other health care professionals to concentrate on their own professional responsibilities (33/38 [87%]), and the expanded CCP coverage improved patient care (29/35 [83%]). Respondents most frequently categorized 23 of the 25 CCP activities as very important.  Conclusions: Expanded CCP coverage was perceived to have a positive effect on both patient care and members of the critical care team. Most CCP activities were perceived as very important. Given the findings of this quality project, novel staffing models are being explored to optimize CCP coverage.  RÉSUMÉ  Contexte : Au cours de la première vague de la pandémie de COVID-19, la couverture par les pharmaciens de soins intensifs (PSI) a été étendue dans 2 unités de soins intensifs médico-chirurgicaux du Queen Elizabeth II Health Sciences Centre, à Halifax (Nouvelle-Écosse) : de 8 heures par jour, 5 jours par semaine, hors jours fériés, la couverture est passée à 8 heures par jour, 7 jours par semaine, y compris les jours fériés.  Objectifs : Décrire les opinions des professionnels de la santé sur la couverture élargie des PSI et leurs perceptions des incidences de celle-ci sur les soins aux patients, ainsi que le rôle des PSI en tant que membres de l’équipe de soins intensifs.  Méthodes : Un sondage électronique comportant 22 questions a été distribué aux professionnels de la santé en soins intensifs pour recueillir les opinions et les impacts perçus de l›élargissement de la couverture des PSI. L’importance perçue des 25 activités des PSI fondées sur des données probantes a été évaluée à l’aide d’une échelle de Likert à 5 points.  Résultats : Trente-huit réponses complètes ont été incluses (taux de réponse de 15 %, basé sur une distribution de l’enquête à 249 professionnels de la santé). La plupart des répondants étaient d’accord ou fortement d’accord avec les affirmations suivantes : « les PSI font partie intégrante de l’équipe de soins intensifs » (34/38, 89 %); « les PSI jouent un rôle important dans l’amélioration des résultats pour les patients » (34/38, 89 %); « la présence des PSI dans l’unité et lors des tournées de soins aux patients permet à d’autres professionnels de la santé de se concentrer sur leurs propres responsabilités professionnelles » (33/38, 87 %); et « la couverture élargie des PSI a amélioré les soins aux patients » (29/35, 83 %). Les répondants ont le plus souvent classé 23 des 25 activités du PSI comme « très importantes ».  Conclusions : L’élargissement de la couverture des PSI était perçu comme ayant un effet positif à la fois sur les soins aux patients et sur les membres de l’équipe de soins intensifs. La plupart des activités des PSI étaient perçues comme très importantes. Compte tenu des résultats de ce projet de qualité, de nouveaux modèles de dotation en personnel sont à l’étude pour optimiser la couverture des PSI. 

Evaluation of patient characteristics, management and outcomes for COVID-19 at district hospitals in the Western Cape, South Africa: descriptive observational study

OBJECTIVES

To describe the characteristics, clinical management and outcomes of patients with COVID-19 at district hospitals.

DESIGN

A descriptive observational cross-sectional study.

SETTING

District hospitals (4 in metro and 4 in rural health services) in the Western Cape, South Africa. District hospitals were small (<150 beds) and led by family physicians.

PARTICIPANTS

All patients who presented to the hospitals' emergency centre and who tested positive for COVID-19 between March and June 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

Source of referral, presenting symptoms, demographics, comorbidities, clinical assessment and management, laboratory turnaround time, clinical outcomes, factors related to mortality, length of stay and location.

RESULTS

1376 patients (73.9% metro, 26.1% rural). Mean age 46.3 years (SD 16.3), 58.5% females. The majority were self-referred (71%) and had comorbidities (67%): hypertension (41%), type 2 diabetes (25%), HIV (14%) and overweight/obesity (19%). Assessment of COVID-19 was mild (49%), moderate (18%) and severe (24%). Test turnaround time (median 3.0 days (IQR 2.0-5.0 days)) was longer than length of stay (median 2.0 day (IQR 2.0-3.0)). The most common treatment was oxygen (41%) and only 0.8% were intubated and ventilated. Overall mortality was 11%. Most were discharged home (60%) and only 9% transferred to higher levels of care. Increasing age (OR 1.06 (95% CI 1.04 to 1.07)), male (OR 2.02 (95% CI 1.37 to 2.98)), overweight/obesity (OR 1.58 (95% CI 1.02 to 2.46)), type 2 diabetes (OR 1.84 (95% CI 1.24 to 2.73)), HIV (OR 3.41 (95% CI 2.06 to 5.65)), chronic kidney disease (OR 5.16 (95% CI 2.82 to 9.43)) were significantly linked with mortality (p<0.05). Pulmonary diseases (tuberculosis (TB), asthma, chronic obstructive pulmonary disease, post-TB structural lung disease) were not associated with increased mortality.

CONCLUSION

District hospitals supported primary care and shielded tertiary hospitals. Patients had high levels of comorbidities and similar clinical pictures to that reported elsewhere. Most patients were treated as people under investigation. Mortality was comparable to similar settings and risk factors identified.

A qualitative investigation of sense of self and continuity in younger adults with stroke

Younger adults are more likely to survive after stroke and their life trajectory is often disrupted. This qualitative study aimed to explore the experience of sense of self and continuity in younger adults after stroke. In-depth semi-structured interviews were conducted with 10 adults (3 male, 7 female) with stroke onset between 18 and 55 years of age. Their interview transcripts were analysed using a phenomenological approach that involved idiographic and nomothetic stages of analysis. Two major themes emerged: (1) centrality of stroke; and (2) impacts of stroke on self. The first theme relates to how central the stroke is in participants' lives. The second theme depicts ways in which stroke influences participants' sense of self. In general, participants who perceived their stroke as having lower centrality also experienced continuity of self, whereas participants who viewed their stroke as higher in centrality experienced interruption of self which often co-existed with growth of self. However, perceptions of stroke centrality and the impacts on self shifted over time and context. These findings extend conceptualisations of post-stroke adjustment by indicating that the impact of stroke on sense of self during early to middle adulthood is linked to how central people perceive their stroke to be within their life story. Younger adults may simultaneously experience their sense of self as continuous, interrupted, and grown after stroke.

The efficacy of prospective memory rehabilitation plus metacognitive skills training for adults with traumatic brain injury: study protocol for a randomized controlled trial

Background

Impairment of prospective memory (PM) is common following traumatic brain injury (TBI) and negatively impacts on independent living. Compensatory approaches to PM rehabilitation have been found to minimize the impact of PM impairment in adults with TBI; however, poor self-awareness after TBI poses a major barrier to the generalization of compensatory strategies in daily life. Metacognitive skills training (MST) is a cognitive rehabilitation approach that aims to facilitate the development of self-awareness in adults with TBI. This paper describes the protocol of a study that aims to evaluate the efficacy of a MST approach to compensatory PM rehabilitation for improving everyday PM performance and psychosocial outcomes after TBI.

Methods/design

This randomized controlled trial has three treatment groups: compensatory training plus metacognitive skills training (COMP-MST), compensatory training only (COMP), and waitlist control. Participants in the COMP-MST and COMP groups will complete a 6-week intervention consisting of six 2-h weekly training sessions. Each 1.5-h session will involve compensatory strategy training and 0.5 h will incorporate either MST (COMP-MST group) or filler activity as an active control (COMP group). Participants in the waitlist group receive care as usual for 6 weeks, followed by the COMP-MST intervention. Based on the sample size estimate, 90 participants with moderate to severe TBI will be randomized into the three groups using a stratified sampling approach. The primary outcomes include measures of PM performance in everyday life and level of psychosocial reintegration. Secondary outcomes include measures of PM function on psychometric testing, strategy use, self-awareness, and level of support needs following TBI. Blinded assessments will be conducted pre and post intervention, and at 3-month and 6-month follow-ups.

Discussion

This study seeks to determine the efficacy of COMP-MST for improving and maintaining everyday PM performance and level of psychosocial integration in adults with moderate to severe TBI. The findings will advance theoretical understanding of the role of self-awareness in compensatory PM rehabilitation and skills generalization. COMP-MST has the potential to reduce the cost of rehabilitation and lifestyle support following TBI because the intervention could enhance generalization success and lifelong application of PM compensatory strategies.

Trial registration

New Zealand Clinical Trials Registry, ACTRN12615000996561. Registered on 23 September 2015; retrospectively registered 2 months after commencement.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1758-6) contains supplementary material, which is available to authorized users.

Effects of response-independent negative reinforcers on negatively reinforced key pecking

Previous research has shown that presenting response-independent positive reinforcers reduces the response rate of an operant maintained by positive reinforcement. The present experiment investigated a similar effect using shock-free time as a negative reinforcer. Brief shocks were delivered in the presence of a distinctive stimulus, and pigeon's key pecks were reinforced by the occasional presentation of a 2-minute shock-free period. Extra 2-minute shock-free periods were added independently of behavior. For each of three pigeons, response rate during shock-on periods declined with added shock-free periods; the more frequently the extra shock-free periods occurred the greater the decline in response rate. This outcome is predicted by extending the Law of Effect to include negative reinforcement.

Integrated delays to shock as negative reinforcement

Rats were shocked at the rate of two per minute until they pressed a lever. In Experiment I, shocks were delivered at variable-time intervals averaging 30 sec; in Experiment II, shocks were delivered at fixed-time intervals of 30 sec. A response produced an alternate condition for a fixed-time period. The shock frequency following a response, calculated over the whole alternate condition, was two per minute. The pattern of shocks in the alternate condition was controlled so that the first shock occurred at the same time as it would have occurred had the response not been emitted; the remaining shocks were delayed until near the end of the alternate condition. Bar pressing was acquired in both experiments. This finding is not explained by two-factor theories of avoidance and is inconsistent with the notion that overall shock-frequency reduction is necessary for negative reinforcement. The data imply that responding is determined by the integrated delays to each shock following a response versus the integrated delays to shock in the absence of a response.

Matching with a key-peck response in concurrent negative reinforcement schedules

In the absence of responding, pigeons were shocked under a variable-time schedule. Responses on either of two keys occasionally produced one minute of shock-free time. That is, pigeons' key pecks were reinforced with shock-free time under concurrent variable-interval schedules. The relative frequency of access to the one-minute shock-free periods was systematically manipulated. Pigeons tended to match both relative response rate and proportion of time spent on each key to the relative frequency of the shock-free periods. A best-fit linear regression equation accounted for over 95% of the variance in both relative response rate and time allocation. The data paralleled closely the results of concurrent schedules of positive reinforcement. These findings are consistent with a description of reinforcement as a transition to a higher-valued situation and suggest that common laws govern choice for both positive and negative reinforcement.

Inhaled particle deposition and body habitus

As a result of the intrapleural pressure gradient that exists in the human lung, both ventilation and particle deposition increase from apex to base. Since the intrapleural gradient varies with the height of the subject, it was decided to compare regional particle deposition in tall, short, and obese subjects to ascertain whether it was influenced by height and weight. Surprisingly, deposition in the vertical plane was not significantly influenced by the height of the subject when corrected for ventilated lung volume. In addition, it was shown that in obese subjects there was increased deposition in the middle zones relative to the apices and bases. This finding persisted after correction for ventilated lung volume and differential attenuation resulting from non-uniform thickness of the fat layer in the obese subject's chest. In the tall and short groups there was a consistent pattern in the concentric deposition of particles with there being a gradient from the central or hilar region to the periphery of the lungs, with the latter showing the most deposition.

The P55 protein affected by v-mos expression is vimentin

Rabbit antiserum prepared against a cyclic 19-amino-acid peptide predicted from the sequence of the viral mos gene (v-mos) of Moloney murine sarcoma virus not only recognized v-mos gene products but also specifically detected a 55,000-Mr polypeptide expressed in a variety of cells that grow on solid surfaces. This normal cellular protein, previously shown to be reduced in amount in cells expressing the v-mos gene, was found to be the intermediate filament structural protein, vimentin. This conclusion was reached by comparing relative mobilities in denaturing gels, isoelectric points, immunoreactivities, location in the cell, and peptide maps.

Radiologic assessment of bile duct complications in liver transplantation: initial experience

Four of the first 24 patients who received 31 orthotopic liver transplantations in our institution developed complications at the site of the surgical anastomosis in the common bile duct. There was one anastomotic stricture, one anastomotic stricture with "bile sludge" deposition, and two cases of bile sludge formation without stricturing at the anastomotic site. The two cases of stricturing required surgical revision while both those of bile sludge accumulation without stricture were successfully managed conservatively. Familiarity with the postoperative appearance of the common bile duct anastomosis and its complications is necessary for the proper assessment of these patients.

Renografin-60 for urography: effect on serum electrolytes and proteins in adults

A prospective study was done on 27 adults to assess the changes in serum electrolytes and proteins induced by bolus administration of 100 ml of the ionic contrast medium diatrizoate meglumine and sodium (Renografin-60) for IV urography. Statistically significant changes in serum sodium, chloride, potassium, calcium, bicarbonate, phosphate, total proteins, and albumin were shown at 5 min postinjection. The mean percentage decreases were sodium 2%, chloride 2%, potassium 9%, calcium 13%, bicarbonate 9%, phosphate 10%, and proteins 15%. A mean 3% increase in serum osmolality was observed. By 30 min, sodium and chloride levels had returned to baseline; potassium, calcium, and albumin values were incompletely recovered; bicarbonate was not significantly changed from 5 min; and phosphate values continued to decrease. An in vitro dialysis experiment in which different volumes of Renografin-60 were dialysed against an electrolyte solution (pseudoserum) produced a dilutional factor of 5 to render a given volume of the contrast isoosmotic with plasma. The observed changes from the baseline values of the electrolytes and proteins up to 10% are therefore assumed to be due to hemodilution resulting from movement of fluid from the extravascular to the intravascular compartment. This study confirms alterations in serum levels of several electrolytes after the use of ionic contrast media beyond simple hemodilution. Although these changes appear not to be clinically significant in this investigation, the alterations in potassium and calcium may contribute to arrhythmias, particularly when hypokalemia or hypocalcemia preexists.

Radiologic findings of retroperitoneal perforation after sphincterotomy

The radiographs of all patients with perforation into the retroperitoneum following endoscopic sphincterotomy, performed between 1981 to 1984 at University Hospital, London, Ontario were reviewed retrospectively. The incidence of perforation was very low. There were only three patients with perforation (1.1%), although 264 sphincterotomies had been performed. The initial and most important radiological findings are air and contrast medium in the retroperitoneum outlining the right kidney; a mottled air and soft tissue density in the right anterior pararenal space due to leak of duodenal contents, bile and air; or both of these findings together. With ultrasonography, a right paranephric fluid collection or an inflammatory mass adjacent to the right kidney or both may be better visualized. Computed tomography, the definitive study, delineates the true extent of the fluid or mass in the anterior pararenal space. Early detection by the radiologist is mandatory to minimize morbidity. To make this diagnosis early requires a high index of suspicion when reviewing the abdominal radiographs of those patients with pain during, or a few hours after, sphincterotomy.

Pleural effusion following liver transplantation

The postoperative chest radiographs of 11 patients who underwent 14 orthotopic liver transplantations were reviewed. Pleural effusions occurred on the right side in all patients and on the left side in four. The effusions were unrelated to primary cardiovascular disease and usually asymptomatic. They were transudates and resolved spontaneously.

Reconstitution of RecBC DNase activity from purified Escherichia coli RecB and RecC proteins

The Escherichia coli RecB protein, normally synthesized in low amounts, has been amplified by linkage of the recB gene to the phage lambda leftward promoter in an expression plasmid. From strains harboring this plasmid, RecB protein has been purified to homogeneity by a simple procedure which includes affinity chromatography on a column of RecC protein bound to agarose. The purified RecB protein has DNA-dependent ATPase activity but no exonuclease activity. RecC protein alone has neither ATPase nor exonuclease activity. However, when combined together, the RecB and RecC proteins show the ATP-dependent double-stranded exonuclease properties characteristic of the RecBC DNase.

Postoperative abdominal wall hematomas have a distinctive appearance on ultrasonography

In six patients a large abdominal wall hematoma developed 1 1/2 to 6 months after operation. In each case differentiation of incisional hernia from hematoma was difficult, but the distinctive appearance on ultrasonography of an ovoid mass with thick straight internal septae, characteristic of hematoma, was noted in all. Ultrasonography also showed the multilocular nature of the lesion which made percutaneous aspiration difficult.

Computed tomography in pelvic liposarcoma: a case report

A case of well-differentiated pelvic liposarcoma with unusual presentation of low-back pain and sciatica, due to the herniation through the greater sciatic notch, is described. Computed tomography is invaluable, not only in predicting the histologic diagnosis, but also in outlining the location, extent, and size of the tumor. This allows accurate planning of the surgical approach.

Oleothorax: expanding pleural lesion

Oleothorax is a method of therapy for pulmonary tuberculosis that was largely abandoned in the 1950s. Its purpose was to cause collapse of the adjacent lung by mechanical means. In the absence of either reactivation of tuberculosis or the development of an empyema, an oleothorax may expand to such an extent as to cause respiratory distress and require removal. The mechanism for this expansion is the stimulation of pleural fluid production by the oil. It is also thought that it may act in a manner similar to a chronic subdural hematoma. This expansion may occur after the oleothorax has been stable for many years, and frequently it is asymptomatic. Four patients were reviewed: one in whom the expansion was so great as to cause respiratory distress, one in whom the enlargement was less rapid and asymptomatic, and two with longstanding oleothoraces in whom the enlargement was more subtle.

Computed tomographic diagnosis of distal radio-ulnar joint disruption

Distal radio-ulnar joint dislocation may be a difficult diagnosis using standard wrist radiographs. We report a patient in whom standard films did not convincingly demonstrate a dislocation which was well seen with computed tomographic scans of the wrist. Computed tomography may be the method of choice for demonstrating distal radio-ulnar joint dislocation when this is suspected clinically but not seen with standard films.

Molecular amplification and purification of the E. coli recC gene product

The level of recC gene expression has been analysed using Mud(bla lac) fusions to the recC promoter. The constitutive level of expression is very low and remains so even under SOS inducing conditions. The recC gene product has been amplified by harnessing the gene to the phage lambda leftward promoter in a plasmid. From cells harbouring this plasmid, RecC protein, which represented approximately 6% of the total cellular protein, was purified to electrophoretic homogeneity.

Cardiac pacemaker leads--a radiographic perspective

To comment on the adequacy of positioning of single- or dual-chambered pacemaker leads requires some knowledge of the type of electrode used. Earlier leads relied upon force transmitted along the body of the lead to the electrode-myocardial interface to maintain positioning. These relatively large stiff leads were placed almost exclusively near the apex of the right ventricle to prevent dislodgement. More recent leads incorporate mechanical fixation devices to maintain position, commonly either tined or screw-in electrodes (or variations of these) representing passive and active fixation mechanisms respectively. The tines are not radiopaque; the screw-in devices are metallic. Such newer electrodes permit the use of smaller, more flexible leads, reduce the necessity for precise positioning, and reduce the frequency of lead dislodgement.

Pitfalls in ultrasonographic diagnosis with fatty infiltration of the liver

Problems in ultrasonography in patients with fatty infiltration of the liver include the possible misinterpretation of small, solid, focal lesions within the liver as being cystic; attributing the relative sonolucency of the pancreas to pancreatitis in the absence of pancreatic disease; and an inability to display normal right renal anatomy using the liver as a "window." Recognition of these problems and careful attention to equipment settings and scanning techniques should prevent errors.

The non-visualized gallbladder by ultrasonography implications and differential diagnosis

The findings in 42 consecutive patients in whom the gallbladder or its lumen were not visualized ultrasonographically were reviewed retrospectively for evidence of gallbladder disease. The series contains two groups of patients--the larger comprised 32 patients in whom the gallbladder was represented only by a dense echogenic focus, with acoustic shadowing, in the right upper quadrant, thought to be due to cholelithiasis in a small contracted gallbladder. The accuracy of this finding in predicting gallbladder disease was 96%. The smaller group consisted of eight patients in whom the gallbladder was not visualized. In seven patients with follow-up, the accuracy of this finding in predicting gallbladder disease was only 71%. Dense echoes in the right upper quadrant were not always due to cholelithiasis but to emphysematous cholecystitis in one patient, porcelain gallbladder in a second, and agenesis of the gallbladder in a third.

Unusual presentations of benign intrathoracic neurogenic tumors

Three patients with benign neural sheath tumors (two neurofibromata, one schwannoma) are reported here. One is known to have von Recklinghausen's disease. All presented in an atypical manner providing a diagnostic challenge. The series comprises one patient with a schwannoma of the left vagus nerve, one with submucosal neurofibromata of the lower one-third of the esophagus and one with an endobronchial neurofibroma. The plain film findings suggested aortic aneurysm, esophageal varices and endobronchial carcinoma respectively.

Halo around the gallbladder--a prognostic sign?

The implications of the finding of a sonolucent zone around the gallbladder, characterized on ultrasonography by loss of definition of the outer (serosal) aspect of the gallbladder wall with a moderately well defined inner (mucosal) surface in patients with signs and symptoms of acute cholecystitis, are described. Of the nine consecutive patients with this finding, five were found to have gangrenous cholecystitis and/or perforation of the gallbladder at surgery. Four of these patients were operated upon within 24 hours of the ultrasound study, one 19 days later. The pathologic basis for this finding is thought to represent massive thickening of the gallbladder wall, with a possible contribution from adherent edematous omentum in the region of the fundus of the gallbladder. Thus this finding of a sonolucent halo about the gallbladder was important in our series, being frequently an indicator of acute cholecystitis complicated by gangrene with or without perforation of the gallbladder.

Pseudomembranous colitis in renal transplant recipients; plain film findings

The plain abdominal film findings in nine renal transplant patients with pseudomembranous colitis were characteristic of but not specific for this entity and most commonly showed "thumb-printing" reflecting submucosal edema (five patients) and a persisting localized segmental ileus in the colon (five patients). Based on the plain film findings, the differential diagnosis will include the acute stages of ulcerative colitis, granulomatous colitis, ischemic colitis and other inflammatory colitides, but the radiologist is in a position to suggest the correct diagnosis in the appropriate clinical setting. A barium study of the colon is not indicated, as diagnosis is usually accomplished by endoscopy. The etiology of this colitis has recently been shown to be a cytopathic toxin of the anaerobic bacterium, Clostridium difficile.

Percutaneous pulmonary aspiration biopsy using the Chiba needle

The Chiba needle was used for percutaneous needle aspiration of lung lesions in 35 patients. Two separate needles were used for each patient at the same sitting. The aspirate was true positive for malignancy in 23 patients and true negative for malignancy in eight patients. Two aspirates were false negative for malignancy and two aspirates, negative for malignancy, were classified as inconclusive due to inadequate patient follow-up. The overall accuracy rate was 94%. Six patients had small pneumothoraces but only one required a chest tube. Appreciable hemoptysis did not occur. The Chiba needle provided an adequate aspirate for cytologic diagnosis. The complication rate using two needles appears to be entirely acceptable.