Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial

Importance

Bleeding is the most common cause of preventable death after trauma.

Objective

To determine the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) when used in the emergency department along with standard care vs standard care alone on mortality in trauma patients with exsanguinating hemorrhage.

Design, Setting, and Participants

Pragmatic, bayesian, randomized clinical trial conducted at 16 major trauma centers in the UK. Patients aged 16 years or older with exsanguinating hemorrhage were enrolled between October 2017 and March 2022 and followed up for 90 days.

Intervention

Patients were randomly assigned (1:1 allocation) to a strategy that included REBOA and standard care (n = 46) or standard care alone (n = 44).

Main Outcomes and Measures

The primary outcome was all-cause mortality at 90 days. Ten secondary outcomes included mortality at 6 months, while in the hospital, and within 24 hours, 6 hours, or 3 hours; the need for definitive hemorrhage control procedures; time to commencement of definitive hemorrhage control procedures; complications; length of stay; blood product use; and cause of death.

Results

Of the 90 patients (median age, 41 years [IQR, 31-59 years]; 62 [69%] were male; and the median Injury Severity Score was 41 [IQR, 29-50]) randomized, 89 were included in the primary outcome analysis because 1 patient in the standard care alone group declined to provide consent for continued participation and data collection 4 days after enrollment. At 90 days, 25 of 46 patients (54%) had experienced all-cause mortality in the REBOA and standard care group vs 18 of 43 patients (42%) in the standard care alone group (odds ratio [OR], 1.58 [95% credible interval, 0.72-3.52]; posterior probability of an OR >1 [indicating increased odds of death with REBOA], 86.9%). Among the 10 secondary outcomes, the ORs for mortality and the posterior probabilities of an OR greater than 1 for 6-month, in-hospital, and 24-, 6-, or 3-hour mortality were all increased in the REBOA and standard care group, and the ORs were increased with earlier mortality end points. There were more deaths due to bleeding in the REBOA and standard care group (8 of 25 patients [32%]) than in standard care alone group (3 of 18 patients [17%]), and most occurred within 24 hours.

Conclusions and Relevance

In trauma patients with exsanguinating hemorrhage, a strategy of REBOA and standard care in the emergency department does not reduce, and may increase, mortality compared with standard care alone.

Trial Registration

isrctn.org Identifier: ISRCTN16184981.

The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial)

BACKGROUND

Haemorrhage is the most common cause of preventable death after injury. REBOA is a novel technique whereby a percutaneously inserted balloon is deployed in the aorta, providing a relatively quick means of temporarily controlling haemorrhage and augmenting cerebral and coronary perfusion, until definitive control of haemorrhage can be attained. The aim of the UK-REBOA trial is to establish the clinical and cost-effectiveness of a policy of standard major trauma centre treatment plus REBOA, as compared with standard major trauma centre treatment alone, for the management of uncontrolled torso haemorrhage caused by injury.

METHODS

Pragmatic, Bayesian, group-sequential, randomised controlled trial, performed in 16 major trauma centres in England. We aim to randomise 120 injured patients with suspected exsanguinating haemorrhage to either standard major trauma centre care plus REBOA or standard major trauma centre care alone. The primary clinical outcome is 90-day mortality. Secondary clinical outcomes include 3-h, 6-h, and 24-h mortality; in-hospital mortality; 6-month mortality; length of stay (in hospital and intensive care unit); 24-h blood product use; need for haemorrhage control procedure (operation or angioembolisation); and time to commencement of haemorrhage control procedure (REBOA, operation, or angioembolisation). The primary economic outcome is lifetime incremental cost per QALY gained, from a health and personal social services perspective.

DISCUSSION

This study, which is the first to randomly allocate patients to treatment with REBOA or standard care, will contribute high-level evidence on the clinical and cost-effectiveness of REBOA in the management of trauma patients with exsanguinating haemorrhage and will provide important data on the feasibility of implementation of REBOA into mainstream clinical practice.

TRIAL REGISTRATION

ISRCTN16184981.

Clinical outcomes following ICSI cycles using surgically recovered sperm and the impact of maternal age: 2004-2015 SART CORS registry

PURPOSE

The aims of this study were (1) to evaluate clinical outcomes after ICSI cycles using surgically recovered sperm and (2) to assess the influence of maternal age on those outcomes.

METHODS

A retrospective cohort study of 24,763 IVF cycles of fresh autologous oocytes and ICSI using surgically recovered sperm reported to the SART CORS database from 2004 to 2015.

RESULTS AND CONCLUSIONS

Older women had significantly longer stimulation (p < 0.001), a lower number of oocytes retrieved (p < 0.001), a lower number of 2PN zygotes (p < 0.001), a lower chance of having a blastocyst transferred (p < 0.001), and a higher number of fresh embryos transferred (p < 0.001). There was no significant association between the number of 2PNs per oocyte retrieved and maternal age (p = 0.214). Both clinical pregnancy rates and live birth rates (LBR) decreased with advanced maternal age (p < 0.001). LBR ranged from 50.4% in women < 30 to 7.2% in women > 42 years, and for cleavage-stage transfers, the LBR ranged from 47.3% in women< 30 to 6.3% in women > 42 years. There were no differences in gestational age at delivery, proportion of term deliveries, preterm deliveries, neonatal birth weight < 2500 g, neonatal birth weight > 4000 g and average birthweight of neonates for singleton pregnancies according to age. For twin pregnancies, women < 30 years had significantly higher number of live births, term deliveries, and lower preterm deliveries than older women. There was a similar number of female (6051) and male neonates (5858; p = 0.2). Overall, pregnancy outcomes with ICSI using surgically recovered sperm are reassuring and comparable to those of ICSI with ejaculated sperm.

The diagnostic value of fine needle aspiration in parotid lumps

INTRODUCTION

Fine needle aspiration (FNA) is a safe and quick method of diagnosing superficial lumps, which aids preoperative planning. However, FNA of the parotid gland has not gained the widespread acceptance noted in other head and neck lumps. The aim of this study was to determine the ability of FNA of the parotid gland to differentiate benign and malignant disease, and to determine the impact on surgical outcome.

METHODS

A retrospective analysis of 201 consecutive parotid operations with preoperative FNA in a large district hospital in the UK was performed. The diagnostic characteristics were calculated for benign and malignant disease, and the impact on surgical procedure was determined.

RESULTS

In identifying benign disease, FNA has a sensitivity of 85% and a specificity of 76%. In detecting malignant disease, FNA has a sensitivity and specificity of 52% and 92% respectively. A false positive on FNA was associated with a higher incidence of neck dissection.

CONCLUSIONS

FNA is a useful diagnostic test. However, owing to low sensitivity, it is necessary to interpret it in the context of all other clinical information.

Touch-less heartbeat detection and measurement-based cardiopulmonary modeling

This paper presents a system for touch-less heartbeat detection and a cardiopulmonary signal modeling approach. Using a vector network analyzer, a microwave system is tested for the detection of the heartbeat signal at a distance of 1 m from a person. The proposed system shows the ability of detecting the heartbeat signals with the possibility of tuning both frequency and power. Measurements are performed at 2.4, 5.8, 10, 16, and 60 GHz, as well as at different power levels between 0 and -27 dBm. Based on measurements performed for both respiration and heart beatings, a model of the measured signals representing the cardiopulmonary activity is presented. The heartbeat rate and the heart rate variability are extracted from the modeling signal using wavelet and classic filters, for SNR between 0 and -20 dB.

Predicted performance of clay-barrier landfill covers in arid and semi-arid environments

Conventional landfill cover systems for municipal solid waste include low-permeability compacted clay barriers to minimize infiltration into the landfilled waste. Such layers are vulnerable in climates where arid to semi-arid conditions prevail, whereby the clay cover tends to desiccate and crack, resulting in drastically higher infiltration, i.e., lower cover efficiency. To date, this phenomenon, which has been reported in field observations, has not been adequately assessed. In this paper, the performance of a cover system solely relying on a clay barrier was simulated using a numerical finite element formulation to capture changes in the clay layer and the corresponding modified hydraulic characteristics. The cover system was guided by USEPA Subtitle-D minimum requirements and consisted of a clay layer underlying a protective vegetated soil. The intrinsic characteristics of the clay barrier and vegetative soil cover, including their saturated hydraulic conductivities and their soil-water characteristic curves, were varied as warranted to simulate intact or "cracked" conditions as determined through the numerical analyses within the proposed methodology. The results indicate that the levels of percolation through the compromised or cracked cover were up to two times greater than those obtained for intact covers, starting with an intact clay hydraulic conductivity of 10(-5)cm/s.

Ultrastructural changes in rat livers perfused in vitro and in vivo with a high dose of methotrexate

Methotrexate is an antifolate that is widely used in the treatment of malignant tumours and other diseases. The present study was undertaken to examine the short-term effects of high doses of methotrexate (HD-MTX) on the ultrastructure and metabolic activity of isolated rat livers. The authenticity of the drug-induced changes was substantiated by the concomitant use of in vivo experiments. Isolated rat livers were infused with HD-MTX via the portal vein for 3 hours (total dose for each liver 2000 mg). For in vivo experiments, each rat received a single intravenous injection of a maximum tolerated dose of MTX (100 mg/kg body weight) that allowed the animals to survive for 3 days. At the end of each experimental period, MTX-treated and control livers were processed for light microscopy (LM), scanning (SEM) and transmission electron (TEM) microscopy. Oxygen consumption and thyroxine metabolism were measured in treated and control isolated livers. With the exception of a few minor differences, the structural changes in the hepatocytes after MTX treatment in vitro and vivo were similar. There were focal changes consisting of disruption of normal hepatic plates and swelling and vacuolation of the hepatocytes, with no clear evidence of restriction to a specific hepatic zone. SEM revealed striking changes in the plasma membrane, the microvillar system, intercellular junctions and the sinusoidal endothelium. TEM revealed disorganized endoplasmic reticulum, dispersion of the polyribosomes, a variety of mitochondrial changes, and glycogen redistribution. In MTX-treated isolated rat livers, the uptake of tetraiodothyronine (T4) was not affected, but triiodothyronine (T3) release was impaired. Oxygen consumption was increased in livers treated with MTX. Employing an organotypic liver perfusion model in conjunction with the in vivo experiment and the use of SEM, TEM and hepatic thyroxine measurements, this investigation revealed that infusion of HD-MTX induced early ultrastructual changes in cell membrane, intercellular junctions and cell organelles and disturbance in the functional integrity of the hepatocytes in isolated rat liver.

Recurrent small bowel obstruction after laparoscopic surgery for gallstone ileus

Gallstone ileus is an uncommon cause of small bowel obstruction. A patient presenting with gallstone ileus was managed in our department by laparoscopic enterolithotomy. Postoperatively, the patient developed recurrent small bowel obstruction due to the presence of a second gallstone. It is therefore important to exclude the possibility of multiple gallstones at the initial operation.

Environmental management of quarries as waste disposal facilities

Problems associated with the disposal of municipal solid waste have become a source of public concern worldwide as awareness of potential adverse environmental impacts and health threats from solid waste has increased. Communities are concerned about the generation and management of solid waste to the extent of refusing to allow new disposal facilities near their homes, often after witnessing the legacy of existing facilities. Under these conditions, the development of national policies for the management of solid waste becomes highly political, all while requiring appropriate technical solutions that ensure environmental protection and proper management plans that support an acceptable solution for the disposal of municipal solid waste. In some locations, the conversion of old quarries into well-engineered and controlled landfills appears as a promising solution to a continuously increasing problem, at least for many decades to come. This paper describes the environmental impacts associated with solid waste disposal in a converted quarry site and the mitigation measures that can be adopted to alleviate potential adverse impacts. Environmental management and monitoring plans are also discussed in the context of ensuring adequate environmental protection during and after the conversion process.

Attenuation-Correction Induced Artifact in F-18 FDG PET Imaging Following Total Knee Replacement

Purpose: The clinical use of PET FDG in the work-up of patients with bone and soft tissue malignant tumors is rapidly increasing. The recognition of any source of artifact, therefore, is important to avoid interpretation pitfalls.Procedures: Two patients with complete knee joint replacement by metallic prosthesis in the course of their treatment for malignant bone and soft tissue sarcoma were evaluated by PET F-18 FDG imaging using a dual head coincidence gamma camera.Results: Both studies demonstrated in the attenuation-corrected images intense increase activity at the joint space between the metallic prosthetic surfaces at the level of the knee joint. No uptake, however, was noted in the same location on the non-attenuation-corrected images. Subsequent bone and thallium-201 scans confirmed the absence of tumor recurrence in the first patient. The second patient had multiple follow up F-18 FDG scans over a period of 16 months that show no changes from the baseline study.Conclusion: In the F-18 FDG PET images of patients with total knee metallic prosthesis, an intense activity tends to be seen in the joint space, only in the attenuation-corrected images. Such pattern of uptake is considered artifactual and should always be verified in the non-attenuated images.

Positive surgical margins with radical retropubic prostatectomy: anatomic site-specific pathologic analysis and impact on prognosis

OBJECTIVES

To correlate the extent and location of positive surgical margins after radical prostatectomy with disease progression.

METHODS

Data on 495 patients who underwent radical prostatectomy by one surgeon were analyzed. All radical prostatectomy specimens were sectioned entirely using 2 to 3-mm step sections by one pathologist. One hundred fifty-one patients (30.5%) had one or more positive surgical margins and were subjected to further detailed analysis. Recurrence was defined as a serum prostate-specific antigen (PSA) level of 0.2 ng/mL and rising on at least two postoperative measurements.

RESULTS

The mean follow-up was 25.3 months (range 3 to 73). The overall recurrence rate was 13.3%. Neoadjuvant hormonal treatment was given to 37 (25%) of those with a positive margin. Patients with positive surgical margins had a significantly higher incidence of recurrence compared with those with negative margins (27.8% versus 6.9%, P = 0.001). The recurrence rate for various locations was 29% apex/urethra, 30% posterior, 33% anterior, 36% lateral, 48% posterolateral, and 57% bladder neck. Time to recurrence was shorter in patients older than 70 years (P<0.055); with a preoperative PSA greater than 10 ng/mL (P<0.0001); with a biopsy Gleason score greater than 7 (P = 0.02); with a prostatectomy Gleason score greater than 7 (P<0.001); with seminal vesicle invasion (P = 0.0001); having more than 1 location of a positive margin (P = 0.002); or having a positive margin at the bladder neck (P = 0.0003) or the posterolateral surface of the prostate (P = 0.02) compared with other locations. Multivariate proportional hazards analyses indicated that age older than 70 (P = 0.005), a prostatectomy Gleason score of 7 (P = 0.015) or 8 to 10 (P = 0.003), and positive margin(s) at the bladder neck (P = 0.003) were independently associated with a shorter time to recurrence among patients with a positive margin.

CONCLUSIONS

In our study, among patients with positive surgical margins, those with multiple positive margins, or a margin involving the bladder neck or the posterolateral surface of the specimen carried a higher risk of progression. A positive margin at the bladder neck appears to be the most significant adverse prognostic indicator. This information may help in decisions regarding additional therapy.

Is there a role for digital rectal examination in the followup of patients after radical prostatectomy?

PURPOSE

We determine the role of digital rectal examination in the followup of patients after radical prostatectomy.

MATERIALS AND METHODS

We retrospectively analyzed data on 501 consecutive patients who underwent radical retropubic prostatectomy between 1992 and 1998, and were followed at the University of Miami. Patients were evaluated at 3 to 6-month intervals after surgery with serum prostate specific antigen (PSA) and digital rectal examination. Biochemical recurrence was defined as PSA greater than 0.2 ng./ml. and increasing on at least 2 consecutive measurements. Local recurrence, detected by an abnormal digital rectal examination, was defined as an induration or nodularity in the prostatic fossa.

RESULTS

Mean followup plus or minus standard deviation was 25.4+/-20.8 months. Disease recurred in 72 patients (14.4%) and was biochemical in all. An abnormal digital rectal examination was noted in 4 patients, none of whom had an undetectable PSA at the time of a palpable abnormality.

CONCLUSIONS

Our results suggest that an abnormal digital rectal examination after radical prostatectomy is always associated with a detectable PSA, which implies that performing a digital rectal examination in the absence of a detectable PSA may not be necessary.

Age as a prognostic factor for disease recurrence after radical prostatectomy

OBJECTIVES

To assess whether age has an impact on biochemical recurrence after radical prostatectomy for localized adenocarcinoma of the prostate.

METHODS

Four hundred eighty-nine consecutive patients who underwent radical retropubic prostatectomy and did not have metastases to the lymph nodes were retrospectively analyzed. Disease recurrence was defined as a serum prostate-specific antigen greater than 0.2 ng/mL and rising on at least two postoperative measurements. Biochemical progression was compared in patients 70 years old or younger and older than age 70. The Kaplan-Meier estimator and Cox's proportional hazards model were employed to investigate the impact of age on time to recurrence. Neoadjuvant androgen deprivation was treated as a stratification variable in the Cox models.

RESULTS

The mean follow-up was 25.4 +/- 20.8 months. The Gleason score and extent of cancer in the pathologic analyses of the prostatectomy specimen was not significantly different between the two groups. Biochemical recurrence was detected in 12% of patients 70 years old or younger and in 25% of those older than 70 (P = 0.01). In multivariate analyses, after adjusting for all prognostic factors, younger age (70 years or younger) was independently associated with a longer time to recurrence (P <0.02).

CONCLUSIONS

Our results suggest that age per se may be an independent prognostic factor for disease recurrence after radical prostatectomy. This implies that patients 70 years old or younger are more likely to benefit from surgery. This information may be useful when counseling patients with clinically localized carcinoma of the prostate.

The value of upper tract cytology after transurethral resection of bladder tumor in patients with bladder transitional cell cancer

PURPOSE

Patients with transitional cell carcinoma of the bladder are at risk for concurrent or subsequent cancer of the upper tract. Traditionally disease is monitored by radiography (excretory or retrograde urography). Some elect to sample the upper tract by obtaining urine for cytology. Are the results meaningful when performed in a patient with bladder cancer?

MATERIALS AND METHODS

We evaluated 27 consecutive patients with transitional cell cancer of the bladder (grade 1 to 3, Ta to T2) with bladder wash for cytology and cystoscopy as well as resection of visible tumor. A 5F ureteral catheter was positioned at each ureteral orifice, flushed with saline and passed into each renal pelvis. Urine was collected for cytology.

RESULTS

Of 19 patients (68%) with high grade (grade 3) bladder cancer 13 had a positive bladder wash, including 6 (32%) with tumor cells detected in the urine from the upper tract. Of 8 patients (38%) with low grade (grade 1 to 2) transitional cell cancer 3 had a positive bladder wash and 2 (25%) had a positive upper tract cytology. All patients had a normal upper tract by excretory or retrograde urography. Ureteroscopy was not performed.

CONCLUSIONS

Given the normal appearance of the upper urinary tract, it is highly unlikely that most, if any, of these patients with bladder cancer have tumor in the upper tract despite tumor cells in urine obtained by retrograde catheterization. Thus, upper tract sampling by a retrograde technique lacks specificity for localizing transitional cell cancer to the upper tract when performed in a patient with bladder cancer.

Early amniocentesis: effect of removing a reduced volume of amniotic fluid on pregnancy outcome

In mid-trimester amniocentesis (MTA), 12-15 ml of amniotic fluid is aspirated for cytogenetic analysis. When a similar volume of amniotic fluid is removed by early amniocentesis (EA), it represents a significant proportion of the total amniotic fluid volume in the first trimester. The fluid depletion, which may persist for 7 to 10 days, is considered to impair development of fetal lungs and extremities and, possibly, contribute towards procedure-related congenital abnormalities and miscarriages. By only removing 7 ml of amniotic fluid, we have demonstrated a total miscarriage rate (3.8 per cent) comparable with previous large studies (Table V), a low incidence of respiratory difficulties at birth (2.7 per cent) and a low incidence of fixed flexion deformities (1.6 per cent), at the expense of a small increase in the incidence of culture failure (2.2 per cent).

Transplacental early amniocentesis and pregnancy outcome

The effect on pregnancy outcome of transplacental needle insertion was studied in 401 consecutive women attending for early amniocentesis between 10 and 14 completed weeks of pregnancy. Transplacental early amniocentesis was associated with a significantly higher incidence (P < 0.001) of blood-stained amniotic fluid taps but a lower incidence (not significant; P > 0.05) of pregnancy loss and miscarriages. Women in the nontransplacental early amniocentesis group had a significantly higher (P < 0.01) incidence of late procedure-related antenatal complications, such as preterm rupture of membranes or preterm labour. Our study showed that transplacental early amniocentesis is a safe procedure; contrary to present recommendations, the study also showed that avoiding the placenta during early amniocentesis is an unnecessary practice.

"Movement" in work status after pain facility treatment

STUDY DESIGN

This was a randomized prospective follow-up study of pain facility treatment of chronic pain patients with low back pain, with return to work and work capacity as the outcome measures.

OBJECTIVES

To determine if after pain facility treatment chronic pain patients "move" in and out of work and in their work capacity; to determine the patterns of "movement;" and to determine the post-pain facility treatment follow-up sampling time points that would maximize the number of chronic pain patients correctly classified according to their final work and work capacity status.

SUMMARY OF BACKGROUND DATA

Past research and empiric observation have indicated that chronic pain patients may "move" after pain facility treatment in and out of work and in their job work capacity. Such "movement" can affect the results of outcome studies.

METHODS

Two hundred thirty-six consecutive chronic pain patients who fit study selection criteria were followed up at 1, 3, 6, 12, 18, 24, and 30 months after pain facility treatment for determination of work and work capacity status and separated according to the pattern of movement. Stepwise discriminant analysis was used to answer the study objectives. "Movement" in and out of work for these chronic pain patients also was compared with the US general population.

RESULTS

Chronic pain patients demonstrated eight work and four work capacity movement patterns. The 24- and 1-month time points predicted final work status correctly for 97.0% and 77.0% of the chronic pain patients, respectively, whereas the most significant predictor for correct work capacity status was the 24-month point. The annual percentage change in employment status for these chronic pain patients was more than in the US general population.

CONCLUSIONS

Because chronic pain patients "move" in and out of employment and for work capacity status after pain facility treatment, future outcome studies using these measures will have to consider carefully the impact of "movement" on their results.

The effects of the antihormones RU486 and tamoxifen on fetoplacental development and placental bed vascularisation in the rat: a model for intrauterine fetal growth retardation

OBJECTIVE

To examine the effect of administration of the antihormones RU486 and tamoxifen in early pregnancy during the period of maximal decidual development in the rat upon fetoplacental and placental bed development.

DESIGN

Case-control study in an experimental animal model.

SETTING

Academic department of obstetrics and gynaecology in a UK medical school.

ANIMALS

Small laboratory animal-the rat-exhibiting haemochorial placentation.

INTERVENTION

Administration of antiprogesterone or antioestrogen (RU486 and tamoxifen respectively) during early pregnancy.

MAIN OUTCOME MEASURES

Weight of the whole pregnancy implant, fetus, mesometrial decidua and placenta; incidence of intrauterine fetal death: and histological changes in the placental bed.

RESULTS

RU486 produced resorption of all implants when administered above a threshold dose, below which it had no effect upon subsequent fetoplacental development. Tamoxifen treatment on days 9 to 11 resulted in significant reduction of decidual weight (35.1% on day 12 of pregnancy, P < 0.001). This was associated with a higher rate of implants or fetuses weighing below the 10th centile (59.6% and 5.7% on day 12, P < 0.001; 42.9% and 7% on day 16, P < 0.001; 25.4% and 7.6% on day 20, P < 0.001 in treated and control animals, respectively). This was also associated with a higher rate of intrauterine fetal death (30.7% on day 16 compared with 4.5% in controls, P < 0.001; 47.8% on day 20 compared to 0.83% in controls, P < 0.001). Histologically, the placental bed of treated animals failed to develop a dilated uteroplacental artery although trophoblast cells migrated endovascularly to a level equivalent to untreated animals.

CONCLUSIONS

RU486 had an all or none dose-dependent effect on fetoplacental development, resulting in either abortion or normal development of pregnancy. Tamoxifen produced significant impairment of decidual development, which was associated with altered blood vessel transformation in the placental bed, impaired fetoplacental development and higher incidence of growth retarded fetuses and fetal death.

A miniaturized rapid paper chromatographic procedure for quality control of technetium-99m sestamibi

A miniaturized rapid paper chromatographic technique (MRPC) for quality control of a technetium-99m sestamibi preparation was developed and compared with the manufacturer's and Hung et al. techniques. The MRPC system involves the use of 6.0x0.5cm Whatman 3MM paper strip developed in ethyl acetate. The procedure was completed within 3min while that of the manufacturer and Hung techniques took 30-35 and 4min respectively. The Rf range of 99mTc-sestamibi using MRPC was 0.55-0.75 while that of the other two techniques was 0.9-1.0. The results indicate that MRPC can be used to separate 99mTc-sestamibi from any 99mTc contaminant that migrates with the solvent front. The MRPC is a fast and effective chromatographic technique for routine quality control testing of 99mTc-sestamibi preparation.

Physician limitations when assessing work capacity: a review

Literature evidence indicates that physicians have great difficulty in translating medical impairment into functional limitation and thereby establishing the work capacity or the residual functional capacity (RFC) of the injured worker. This is especially true for the chronic pain patient (CPP). Development of quantitative methods for the measurement of functional capacity (FC), have not improved the problems involved in the measurement of RFC and the translation of RFC into the demand minimum functional capacity (DMFC) of some job or jobs. The relationship between FC, RFC, work capacity and DMFC is reviewed. We have developed a method/battery for measuring RFC in CPPs utilizing the Dictionary of Occupational Titles (DOT) which is readily translatable into DMFC of some job or jobs. Suggestions are made for future directions in the measurement of work capacity.

Epithelial localization of insulin-like growth factor binding protein 1 in the uterus of the rat during pregnancy, deciduoma-bearing pseudopregnancy and hormone treatment

A monospecific antibody was used to determine the immunocytochemical localization of insulin-like growth factor binding protein 1 (IGFBP-1) in the rat uterus. Immunoreactive IGFBP-1 was first detected from day 5 of pregnancy in the luminal and glandular epithelium. However, immunoreactivity was most intense from day 6 in the glandular epithelium, where it was associated with apically located granules. Immunoreactive glands were located only in non-decidualized endometrium, which was limited at the implant site to a thin basal layer by growth of the antimesometrial decidua from day 7. However, glands and associated immunoreactive IGFBP-1 were prominent in the inter-implant sites until day 9, although they were detected throughout pregnancy. Similar reactivity was detected in the glands of the basal endometrium in deciduomata-bearing animals, but these decreased in number from day 7 of pseudopregnancy. No immunoreactivity was detected during the oestrous cycle but could be induced in ovariectomized animals by sequential oestradiol and oestradiol plus progesterone treatment. The observations were consistent with IGFBP-1 representing a secretory product of the glandular epithelium and could either play a role in development of the trophoblastic component of the conceptus during the pre-placental period of anti-mesometrial implantation or in the endometrium acting as an inhibitor of local IGF-I action and in either case by transporting IGF-I from the stromal to the glandular luminal environment.

Measuring residual functional capacity in chronic low back pain patients based on the Dictionary of Occupational Titles

STUDY DESIGN

This study designed and tested a functional battery based on the Dictionary of Occupational Titles (DOT).

OBJECTIVES

Such a battery can be used to measure residual functional capacity (RFC) in chronic pain patients (CPP) and results can be matched against the demand minimum functional capacities (DMFC) of DOT jobs.

SUMMARY OF BACKGROUND DATA

Physicians have difficulty translating medical impairment into functional limitation and thereby establishing the RFC of CPPs.

METHODS

The DOT, a USA government publication, provides information about physical demands of every USA job according to 36 factors and subfactors. The authors defined and developed a functional battery based on these factors/subfactors. This battery was tested on 67 consecutive CPPs to determine the percentage of CPPs able to pass specific job factors and the full battery and return to some DOT job, and evaluated the effects of pain on battery performance. The data were factor analyzed.

RESULTS

The battery determined if CPPs could perform DOT job factors and had the necessary RFC to be placed in a DOT job. The vast majority of CPPs could not pass the full battery and the presence of pain and original job classification predicted whether a CPP could perform a job factor. Factor analyses grouped the factors into four independent categories supporting the design of the battery.

CONCLUSION

The battery can assess whether CPPs are able to return to work.

Functional capacity and residual functional capacity and their utility in measuring work capacity

OBJECTIVE

The pain physician is often asked to establish the medical impairment of the chronic pain patient (CPP) and from that determination ascertain the work capacity of the CPP. Functional capacity (FC) testing has recently been introduced as a more objective and accurate way of facilitating the determination of work capacity. However, there are conceptual problems with the measurement of FC. These will be reviewed and the relationship of FC to residual functional capacity (RFC) will be determined. Finally, a method for measuring RFC in a job-specific manner will be suggested.

DATA SOURCES

The literature in reference to the measurement of medical impairment, FC, and RFC was reviewed.

STUDY SELECTION

Studies appropriate to the objective of this review were selected for inclusion.

CONCLUSIONS

The FC and RFC are poorly defined. Lack of definition has interfered with design of appropriate test batteries specific to work capacity. To circumvent this problem a job-specific RFC measurement method is suggested. This method is based on the Dictionary of Occupational Titles.

Is cyclosporine toxic to the heart?

Cardiotoxicity caused by cyclosporine was studied in experimental rats by the uptake of radiopharmaceuticals (technetium 99m-labeled pyrophosphate and indium 111-labeled antimyosin) and histologic examination of heart tissues. A dose of 50 mg/kg (body weight) of cyclosporine and an equal volume of vehicle (cremophor-EL) were injected into the rats subcutaneously for 7 or 11 consecutive days. A statistically significant difference (p < 0.05) was noted between the uptake of the radiopharmaceuticals in the hearts of cyclosporine-treated rats compared to the control rats. For 99mTc pyrophosphate, the cardiac uptake ratios of cyclosporine-treated rats to control rats were 2.13 and 4.08 for 7-day and 11-day treatment periods, respectively. For 111In antimyosin, the ratios were greater than 2 for both 7-day and 11-day treatment periods. Histologically, vacuoles were found in single or focal groups of myocytes with interstitial edema in the hearts of cyclosporine-treated rats compared to the control rats. The results of both the uptake of the radiopharmaceuticals and the histologic evidence indicate cell injury in the hearts of cyclosporine-treated rats. Cyclosporine therefore seems to be toxic to the heart tissue.

Intestinal platelet trapping after traumatic and septic shock. An early sign of sepsis and multiorgan failure in critically ill patients?

OBJECTIVES

Patients resuscitated after severe traumatic or septic shock were studied with reference to the behavior of radiolabeled platelets in vital organs, the occurrence of sepsis, and multiorgan failure. These findings were compared with findings of patients who had sustained severe head trauma, but had reportedly not been in shock.

DESIGN

Prospective, clinical trial of consecutive patients.

SETTING

Multidisciplinary ICU.

PATIENTS

Thirteen critically ill patients who were considered at high risk for developing multiorgan failure. These patients had all been resuscitated after major trauma (Injury Severity Score 50.2 +/- 7.2) or severe septic shock (group A, Acute Physiology and Chronic Health Evaluation [APACHE II] score 21.7 +/- 4.4). For comparison, six patients with head trauma, who were considered at low risk for multiorgan failure were studied (group B, Injury Severity Score 26.0 +/- 5.1 and APACHE II score 12.3 +/- 2.4).

MEASUREMENTS

Platelet trapping was studied in multiple organs by external detection of platelets labeled with 111indium-oxine. Measurements were started on the third day and continued for seven consecutive days or until death.

RESULTS

Eight of 13 patients in group A developed sepsis and multiorgan failure and six of these eight patients died 8 to 29 days after the initial insult. No patient in group B developed multiorgan failure, and all survived. The patients in group A had significant increases in platelet trapping in the liver and the lungs, but the increase was significantly (p less than .01) greater in the nonsurvivors than in the survivors. All the nonsurvivors had markedly increased platelets sequestration in the intestine (less than 10 times the activity in blood), but none of the survivors had increased platelet sequestration in the intestine (p less than .01). This increase was recorded 1 to 4 days before the first clinical signs of sepsis and 3 to 7 days before the development of multiorgan failure. No patient in group B had increased activity in the liver or in the intestine, and only one patient had a slight increase in the lung.

CONCLUSIONS

The results indicate that, in patients resuscitated after severe traumatic or septic shock, increased sequestration of platelets in the intestine, as measured by external detection of radioisotope-labeled autologous platelets, may precede clinical signs of sepsis and multiorgan failure and may possibly predict the outcome.

Lymphoscintigraphy in lymphedema of the lower limbs using 99mTc HSA

Edema of the lower limbs is a difficult clinical problem. Edema could be due to stasis, obstruction of the lymphatic channels, or increased production of lymph beyond the drainage capacity of the lymphatic vessels. Sometimes it is difficult to differentiate among these varieties. Lymphoscintigraphy was performed in 164 patients complaining of swelling of the lower limbs, 2 women patients with lymphedema of the upper limbs following radical mastectomy, and 5 volunteers. All patients were injected with 1 mCi of 99mTc human serum albumin intradermally in the medial web on the dorsum of each foot. Data were acquired dynamically for both inguinal regions for forty-five minutes with a gamma camera interfaced with a computer. Static images were taken at ninety minutes for both legs and thighs and for the pelvis. Time activity curves were generated for the equal regions of inguinal nodes on both inguinal sides. The following patterns were recognized: normal pattern in 5 volunteers and in 57 patients, enhanced flow pattern in 17 patients, stasis with mild obstruction in 72 patients, and marked stasis with obstruction in 20 patients.

Tc-99m human serum albumin lymphoscintigraphy in lymphedema of the lower extremities

Edema of the lower extremities is a difficult clinical problem. It can be due to stasis, obstruction of the lymphatic channels, increased production of lymph beyond the drainage capacity of the lymphatic vessels. It is often difficult to differentiate between these varieties. Lymphoscintigraphy was performed on 164 patients complaining of swelling of the lower extremities and on 5 volunteers. All patients were injected with 1 mCi of Tc-99m human serum albumin (HSA) intradermally in the medial web of the dorsum of each foot. Data were acquired dynamically for both inguinal regions for 45 minutes, and static images of the legs, thighs, and pelvis were taken at 90 minutes. Time activity curves were generated for the equal regions of inguinal nodes on both inguinal sides. The following patterns were recognized: normal (5 volunteers and 57 patients), enhanced (17 patients), stasis with mild obstruction (70 patients), and marked stasis with obstruction (20 patients).

The use of 125I-HIPDM for studying tissue response due to toxic effects of cyclosporin-A in rats

125I-HIPDM was used to study the response of various tissues in cyclosporin-A, CyA, treated and control rats. The rats were given 50 mg/kg of CyA for 7 consecutive days. The liver, kidney and heart showed significant increase while the spleen had a pronounced decrease in the uptake of 125I-HIPDM in CyA treated compared to control rats. This difference in the uptake of 125I-HIPDM between CyA treated and control rats is assumed to be the tissue response to toxic effects of CyA. The results indicate that CyA is toxic to liver, kidney, spleen and probably heart. There was no difference in the uptake of 125I-HIPDM in the lung and brain of CyA treated and control rats. This lack of difference is assumed to indicate that CyA does not adversely affect the lung and brain.

Segmental analysis of SPECT 99mTc-methoxy isobutyl isonitrile and 201Tl myocardial imaging in ischaemic heart disease

To study the potential usefulness of 99mTc-methoxy isobutyl isonitrile (99mTc-MIBI) as a substitute for 201Tl in assessing patients with ischaemic heart disease, 24 patients underwent 1 day rest and exercise 99mTc-MIBI single photon emission computerised tomography (SPECT) 1 week after SPECT exercise 201Tl. All patients were catheterized within 1 month after myocardial imaging. In 17 patients, resting first pass radionuclide angiography (FPRNA) was performed with 99mTc-MIBI. The heart to lung ratio for 99mTc-MIBI and 201Tl was calculated both at rest and exercise. The segmental analysis for myocardial perfusion reveals that 87/96 segments (91%) were correctly classified by SPECT 201Tl and 84/96 segments (88%) were correctly classified by 99mTc-MIBI. A significant correlation was present between LVEF measured by 99mTc-MIBI FPRNA and contrast ventriculography (r = 0.85, P less than 0.0001). The heart to lung ratio both at rest and exercise for 99mTc-MIBI is significantly higher than 201Tl (P less than 0.01 and less than 0.001 respectively). We conclude that 99mTc-MIBI is a promising agent for simultaneous evaluation of myocardial perfusion and cardiac function.

Preparation and evaluation of Tc-99m hydroxyethyl starch as a potential radiopharmaceutical for lymphoscintigraphy: comparison with Tc-99m human serum albumin, Tc-99m dextran, and Tc-99m sulfur microcolloid

Tc-99m hydroxyethyl starch (Tc-99m HES) prepared with a labeling efficiency greater than 95% was evaluated in rabbits for visualization of lymphatic channels and lymph nodes, and the findings compared with Tc-99m human serum albumin (Tc-99m HSA), Tc-99m dextran (Tc-99m DXT), and Tc-99m sulfur microcolloid (Tc-99m SMC). Tc-99m HES showed good visualization of lymphatic channels and regional nodes and it had the highest clearance rate from the injection site (p less than 0.01). Tc-99m HES showed greater uptake by the nodes than Tc-99m DXT (p less than 0.001) at 90 minutes post-injection. The concentration of Tc-99m HES in the lymphatic channels was higher than that of Tc-99m SMC at 90 minutes post-injection (p less than 0.001). Preliminary clinical studies of Tc-99m HES yielded high quality lymphoscintigrams of the leg, and the pelvic and para-aortic lymph nodes in less than 10 minutes post-injection. In addition, partially and completed obstructed lymphatics could be differentiated from normal lymphatic pathways. In conclusion, Tc-99m HES is a promising radiopharmaceutical for imaging of lymphatic channels and nodes.

The hollow skull: a sign of brain death in Tc-99m HM-PAO brain scintigraphy

The advantage of Tc-99m HM-PAO, a newly introduced compound for brain perfusion imaging, is illustrated in three patients with suspicion of brain death. With Tc-99m HM-PAO, the carotid flow study is not essential, as it is in the Tc-99m pertechnetate carotid angiogram; planar images are equally useful; and there is no need for SPECT images. For the diagnosis of brain death, Tc-99m HM-PAO can be injected in the intensive care unit and planar images can be obtained at a later time using a mobile camera or whenever the patient can be moved to the nuclear medicine department.

Is 99Tcm hexamethyl-propyleneamine oxime uptake in the tissues related to glutathione cellular content?

The relationship between the concentration of tissue glutathione (GSH) content and uptake of 99Tcm HMPAO in Sprague Dawley rats was investigated. The GSH content of rat tissue was depleted with diethyl-maleate (DEM) and the ratio of GSH in control to GSH depleted rat was approximately twice that in the brain, liver, kidney, spleen and lung. The GSH content in all the organs studied except the liver had no statistically significant relationship with the uptake of 99Tcm HMPAO. The apparent increase of radioactivity in the liver was due to longer retention of 99Tcm HMPAO. This longer retention was due to stasis of bile flow as confirmed by subsequent experiments in which cholecystokinin (CCK) was administered to GSH depleted rats and compared to the uptake of GSH depleted rats without injection of CCK.

Comparison of 99Tcm-mercaptoacetyltriglycine and 131I-orthoiodohippurate in determination of effective renal plasma flow (ERPF)

Recent studies have suggested that 99Tcm-labelled mercaptoacetyltriglycine (99Tcm-MAG3) is a potential replacement for 131I-orthoiodohippurate (131I-OIH). The two radiopharmaceuticals were studied in 19 patients with varying degrees of renal impairment, for comparison of effective renal plasma flow (ERPF). All patients were injected i.v. with 2-3 mCi 99Tcm-MAG3 and 250-300 microCi of 131I-OIH simultaneously in separate arms to avoid any chemical incompatibility. Serial digital images were acquired simultaneously for 99Tcm-MAG3 and 131I-OIH at 15 s per frame for 30 min. The renogram curve was generated and ERPF value was calculated for each kidney using both radiopharmaceuticals and applying the same computer program (Schlegel's program). In all cases, the 99Tcm-MAG3 and 131I-OIH renogram curves were quite similar. The values of ERPF of 99Tcm-MAG3 were not significantly different from those of 131I-OIH studies (paired t test, p less than 0.01). The correlation coefficient between the two methods was 0.95 (p less than 0.001) with a linear regression equation Y = -12.96 + 0.995X, where Y = ERPF determined by 131I-OIH and X = ERPF determined by 99Tcm-MAG3. This study indicates that 99Tcm-MAG3 is a useful 99Tcm replacement for 131I-OIH in the determination of ERPF and generation of renogram curves.

Efficacy of ceruletide controlled saline infusion for retained ductal stones after cholecystectomy and exploration of the common bile duct

The synthetic peptide ceruletide induces maximal relaxation of the sphincter of Oddi. In a preliminary communication, ceruletide controlled saline infusion of the common bile duct (CBD) was found to be effective in promoting the passage of retained ductal calculi after cholecystectomy and exploration of the common bile duct. This paper reports on the further experience with this simple treatment which was administered to 27 patients with retained ductal calculi in 16 different hospitals within the U.K. The success of the procedure was documented by repeat T-tube cholangiography. Passage of stones into the duodenum was documented in 13 patients (48%) with complete clearance in 9 (33%) following one saline infusion/ceruletide treatment. The radiological stone size ranged from 3 to 15 mm. Within this range, there was no correlation between a successful outcome and size of retained stones. The duration of the saline T-tube infusion during ceruletide treatment averaged 54.7/min (SD 14.3). There was no correlation between flow rate of saline through the T-tube and a successful outcome. A significant inverse correlation was observed between the CBD pressure during ceruletide controlled saline T-tube infusion and successful stone passage (chi 2 = 9.9, P less than 0.01). Ampullary impaction by a stone was encountered in one patient. These results are encouraging and indicate that pharmacological dilatation of the sphincter of Oddi together with saline infusion is effective in the management of retained stones after exploration of the common bile duct. This treatment, which does not require any special expertise, should be tried in the first instance before more invasive procedures are used.

Splenic implants: evaluation with radionuclide methods

The viability of omental splenic implants placed in 16 patients who had undergone splenectomy was assessed with 37 technetium-99m tin colloid studies and five studies with Tc-99m-labeled denatured red blood cells (RBCs). Indications for splenectomy included trauma in eight patients, schistosomal (Bilharzial) portal hypertension in six, splenic artery aneurysm in one, and Wiskott-Aldrich syndrome in one. Studies were done within the 1st month and at various intervals up to 13 months after surgery. Implants in five of eight trauma patients were seen during the 1st month, and implants in seven of seven were seen after 6 months (one patient could not be followed up). Three of six implants in cases of portal hypertension were seen in the 1st month and four of four at 6 months (two patients were not followed up). In two of the five studies with denatured RBCs, Tc-99m tin colloid study was also done 48 hours later; in these cases denatured RBCs were more successful in showing the implants. The authors conclude that radioisotopic procedures are valuable in following up the viability of splenic implants. The "take" of splenic implants in patients with schistosomiasis is equally successful to that in trauma patients.

99Tcm hydroxyethyl starch: a potential radiopharmaceutical for lymphoscintigraphy

The usefulness of 99Tcm hydroxyethyl starch (99Tcm HES) has been evaluated for visualization of lymphatic channels and lymph nodes. 99Tcm HES was prepared with a labelling efficiency higher than 95%. Its usefulness for imaging lymphatic channels and lymph nodes were compared to 99Tcm human serum albumin (99Tcm HSA), 99Tcm dextran (99Tcm DXT) and 99Tcm sulphur micro colloid (99Tcm SMC) in rabbits. 99Tcm HES showed a good visualization of lymphatic channels and lymph nodes and it had the highest clearance rate from the injection site (P less than 0.01). 99Tcm HES showed higher uptake by the nodes than 99Tcm DXT (P less than 0.001) at 90 min post injection. The concentration of 99Tcm HES in the lymphatic channels was higher than that of 99Tcm SMC at 90 min post injection (P less than 0.001). Preliminary studies of 99Tcm HES in humans provided high-quality lymphoscintigrams of the leg, and the pelvic and para aortic lymph nodes in less than 10 min post injection. In addition, partially and completely obstructed lymphatics could be differentiated from the normal one. Hence 99Tcm HES is a potential radiopharmaceutical for visualization of lymphatic channels and nodes.

Development of an animal model using a closed system to study the sensitivity of a radiopharmaceutical for the detection of gastrointestinal bleeding

An experimental animal model using a closed system to study the sensitivity of radiopharmaceuticals for the detection and localization of gastrointestinal (GI) bleeding site in a sheep was developed. This model was validated with 99mTc-DTPA. Radioactivity as low as 85.47 +/- 13.32 kBq in a volume of 2.1 +/- 0.14 ml at a bleeding rate of 0.07 ml/min was detected. Simulated intermittent bleeding experiments indicated that at 1 h after injection of 99mTc-DTPA there was still enough circulating radioactivity to bleed into the gut and that it was possible to perform repeat injection of 99mTc-DTPA as early as 2 h after the first injection.

Development of an Animal Model Using a Closed System to Study the Sensitivity of a Radiopharmaceutical for the Detection of Gastrointestinal Bleeding

An experimental animal model using a closed system to study the sensitivity of radiopharmaceuticals for the detection and localization of gastrointestinal (Gl) bleeding site in a sheep was developed. This model was validated with 99mTc-DTPA. Radioactivity as low as 85.47 ± 13.32 kBq in a volume of 2.1 ±0.14 ml at a bleeding rate of 0.07 ml/min was detected. Simulated intermittent bleeding experiments indicated that at 1 h after injection of 99mTc-DTPA there was still enough circulating radioactivity to bleed into the gut and that it was possible to perform repeat injection of 99mTc-DTPA as early as 2 h after the first injection.