Effectiveness of the quadrivalent high-dose influenza vaccine for prevention of cardiovascular and respiratory events in people aged 65 years and above: Rationale and design of a real-world pragmatic randomized clinical trial

BACKGROUND

Influenza has been an acknowledged cause of respiratory disease for decades. However, considerable related, and often unappreciated, disease burden stems from cardiovascular complications, exacerbations of underlying medical conditions and secondary respiratory complications, with the highest burden in the elderly. This novel study combines the gold standard method of a randomized controlled trial with real-world data collection through national registries, to assess the relative effectiveness of high-dose (QIV-HD) vs standard-dose quadrivalent influenza vaccine (QIV-SD) in preventing cardio-respiratory hospitalizations in a large cohort of adults aged ≥65 years.

METHODS AND RESULTS

This trial (NCT04137887) is a Phase III/IV, modified double-blinded, randomized, registry-based trial, conducted by the Finnish Institute for Health and Welfare (THL). Participants (n>120 000) are being enrolled over multiple influenza seasons and randomized (1:1) to receive QIV-HD or QIV-SD. Participant follow-up is based on data collection up to 11 months post-vaccination using Finnish national health registries. The primary objective is to demonstrate the relative superior effectiveness of QIV-HD over QIV-SD in preventing cardio-respiratory hospitalizations up to 6 months post-vaccination. Safety will be assessed using automated online tools throughout the study, with causality assessed using statistical and probabilistic methods; serious adverse reactions and adverse events of special interest will be investigated individually.

CONCLUSION

This large, real-world, randomized study will provide valuable insight into the contribution of influenza in causing severe cardio-respiratory events, and the role of vaccination with QIV-HD in reducing these outcomes compared to the current standard of care.

FUNDING

Sanofi Pasteur.

Normative values for tympanometry in 4—5-year-old children: Valores normativos para la timpanometria en niños de 4—5 años de edad

The objective of this study was to determine normative values for tympanometric variables for 4-5-year-old children. Tympanometry was performed at a pre-scheduled visit at the age of 49-68 months on children recruited to a follow-up visit in a vaccine efficacy trial (n=756 children). Tympanograms obtained successfully from healthy ears were analysed. At the time of the visit, mean static acoustical admittance (SAA) was 0.52 cm3, mean tympanometric peak pressure (TPP) was -48 daPa, and mean tympanometric width (TW) was 101. Compared to results obtained for the same study population at 24 months of age, the SAA had increased significantly with age, while the values for TPP and TW had decreased with age. A history of previous tympanostomy tubes increased the admittance of the tympanic membrane by producing atrophic scars. Thus, the tympanograms obtained from ears with previous tubes were considerably higher and narrower (high SAA and low TW). In conclusion, this study further emphasizes the need for age-specific normative values for interpretation of SAA and TW.

Detection of middle-ear fluid in children with spectral gradient acoustic reflectometry: a screening tool for nurses?

OBJECTIVE

To evaluate the validity of spectral gradient acoustic reflectometry (SG-AR) in the hands of nurses in screening children for middle-ear fluid (MEF).

DESIGN

Prospective, blinded study.

SETTING

A satellite study within the Finnish Otitis Media Vaccine Trial in primary care in 1995-99.

PATIENTS

Some 739 ear examinations among a cohort of 271 children under the age of 2 years during different healthcare contacts (acute sick visits, check-up visits after otitis media, and scheduled healthy control visits at 24 months of age).

MAIN OUTCOME MEASURES

Specificity, sensitivity and positive and negative predictive values of SG-AR performed by nurses in detecting MEF using pneumatic otoscopy by trained physicians as a reference.

RESULTS

SG-AR was successful in 585 (79%) ears. None of the cut-off points assessed resulted in both excellent sensitivity and specificity. Nevertheless, at the sick visits, positive predictive values at 50 and 60 degrees were as high as 94% and 89%, respectively. However, negative predictive value for the cut-off point of 100 degrees was considerably lower, at 75%. At the non-acute visits, negative predictive values were excellent.

CONCLUSION

SG-AR is a useful device for nurses in screening MEF among children. It detects ears with both very high and very low probability of MEF and is especially effective in detecting MEF during sick visits and in ruling out MEF among non-acute patients. We recommend the use of the SG-AR cut-off point of 60 degrees as a sign of MEF when screening sick children, and the cut-off point of 100 degrees as a sign of a healthy ear among non-symptomatic patients.

Salivary antibodies induced by the seven-valent PncCRM conjugate vaccine in the Finnish Otitis Media Vaccine Trial

We studied salivary antibodies induced by a seven-valent pneumococcal conjugate vaccine (PncCRM). Healthy Finnish children (n=115), a subcohort of the Finnish Otitis Media (FinOM) Vaccine Trial, were immunised either with the PncCRM or a control vaccine (hepatitis B) at the age of 2, 4, 6, and 12 months. Salivary IgG, IgA, IgA1, IgA2 and sIg for serotypes 6B, 14, 19F, and 23F were measured at 7 and 13 months of age, and IgG and IgA also at 4-5 years of age. The PncCRM could induce both salivary anti-Pnc polysaccharide IgG and IgA. However, by the age of 4-5 years IgA concentrations had increased in both groups and were similar. The increases in IgA concentrations were mostly of IgA1 subclass. The difference between the PncCRM and the control group was more notable for serotypes 6B, 14 and 23F than for serotype 19F. We could not find evidence for the development of mucosal immunologic memory after vaccination with the PncCRM.

Protective Efficacy of a Second Pneumococcal Conjugate Vaccine against Pneumococcal Acute Otitis Media in Infants and Children: Randomized, Controlled Trial of a 7-Valent Pneumococcal Polysaccharide-Meningococcal Outer Membrane Protein Complex Conjugate Vaccine in 1666 Children

To assess the efficacy of a 7-valent pneumococcal polysaccharide-meningococcal outer membrane protein complex conjugate vaccine (PncOMPC) against acute otitis media (AOM), 1666 infants were randomly assigned to receive either PncOMPC or control vaccine (hepatitis B vaccine) at 2, 4, 6, and 12 months of age. Of the 835 children assigned to receive PncOMPC, 187 received a 23-valent pneumococcal polysaccharide vaccine (PncPS) at 12 months of age instead. Whenever AOM was diagnosed, middle ear fluid was aspirated for bacterial culture. In the PncOMPC and control groups, there were 110 and 250 AOM episodes, respectively, in children between 6.5 and 24 months of age that could be attributed to vaccine serotypes, which indicates a vaccine efficacy of 56% (95% confidence interval, 44%-66%). The serotype-specific efficacy ranged from 37% for 19F to 82% for 9V. The 2 boosters seemed to provide equal protection against AOM, but PncPS induced markedly higher antibody concentrations. The efficacy of PncOMPC was comparable to that of the recently licensed pneumococcal conjugate vaccine.

The effect of a pneumococcal conjugate vaccine on the risk of otitis media with effusion at 7 and 24 months of age

OBJECTIVE

To explore the effect of a pneumococcal conjugate vaccine on the risk of otitis media with effusion and to search for subgroups in which the vaccine had a higher or lower effect.

METHODS

Analyses were performed on data from the Finnish Otitis Media Vaccine Trial, a randomised controlled double-blind trial to evaluate the efficacy of pneumococcal conjugate vaccination against acute otitis media. Data on the vaccination effect against otitis media with effusion were obtained by means of symptom interview and pneumatic otoscopy during pre-scheduled follow-up visits at the age of 7 and 24 months. Two endpoint definitions were considered: otitis media/tube (otitis media or tympanostomy tube in situ (OM/T)) as the primary endpoint and otitis media with effusion as the secondary endpoint. No evidence was found of an age-dependent association with vaccination effect. Therefore, the final marginal logistic regression analyses were performed on the combined data from the two follow-up visits.

RESULTS

The risk of otitis media tended to be lower in the pneumococcal vaccine group. The odds ratio for otitis media/tube was 0.94 (95% confidence interval 0.77-1.14) and the odds ratio for otitis media with effusion was 0.90 (95% confidence interval 0.69-1.19). Presence of older siblings increased the risk of otitis media/tube and otitis media with effusion at 7 months of age. In addition, it appeared that children without older siblings and attending day-care at 24 months of age tended to benefit more from the pneumococcal conjugate vaccine. In this subgroup, the odds ratio for otitis media/tube was 0.81 (95% confidence interval 0.55-1.20) and for otitis media with effusion the odds ratio was 0.43 (95% confidence interval 0.22-0.86).

CONCLUSION

The effect of pneumococcal conjugate vaccination on the risk of otitis media with effusion was concordant with the efficacy seen against acute otitis media, although not distinguishable from no effect in the overall analysis. In children without older siblings, vaccination appeared to reduce the point prevalence of otitis media with effusion; this effect was not apparent in children with older siblings.

Effect of short-term treatment with regular or high doses of omeprazole on the detection of Helicobacter pylori in bleeding peptic ulcer patients

BACKGROUND

It is unknown whether short-term regular or high-dose omeprazole has any influence on the colonization of Helicobacter pylori in the stomach. We therefore studied the effect of 3-day treatment of 2 different doses of omeprazole.

METHODS

H. pylori-positive patients with peptic ulcer bleeding (n = 101) were randomized to receive either a regular dose (20 mg/day for 3 days) (n = 51) or a high dose of omeprazole (80 mg bolus + 8 mg/h infusion/day for 3 days) (n = 50). H. pylori status was assessed by histology and urease testing of gastric biopsies pre-entry and after 3-day therapy.

RESULTS

With the high dose of omeprazole, tests for the diagnosis of H. pylori became negative significantly more often than with the regular dose (60% versus 27.5%, P=0.001 (any test), 67.6% versus 31.7%, P=0.003 (histology) and 82.2% versus 43.6%, P=0.001 (urease test)).

CONCLUSION

Conversion of the H. pylori tests negative after 3-day treatment of omeprazole is dose-dependent. The diagnosis of H. pylori infection depends on the timing of biopsies in relation to the beginning of proton-pump inhibitor treatment. If samples to find H. pylori are not taken before the treatment, the presence of the bacteria may be overlooked.

Real-time quantitative PCR for the detection of Streptococcus pneumoniae in the middle ear fluid of children with acute otitis media

PCR based on the amplification of pneumolysin gene fragments has previously been applied to demonstrate Streptococcus pneumoniae in clinical specimens. Here, a real-time PCR method for the detection and quantification of pneumococci by amplifying a 206-bp fragment of the pneumolysin-encoding gene is described. The amplified fragments were detected simultaneously using fluorescent-labeled sequence-specific hybridization probes. The applicability of the assay to clinical samples was evaluated by studying 50 middle ear fluid (MEF) specimens from children with acute otitis media. Twenty-six of the MEF samples were positive by real-time PCR and the numbers of genome equivalents detected varied from 90 to 88,000/microl in 17 culture-positive samples and from 1 to 1,200/microl in 9 culture-negative samples. The results were compared to culture findings and to results obtained by using agarose gel electrophoresis or Europium-labeled hybridization probes for the detection of amplification products of conventional PCR. The sensitivity and specificity of the real-time PCR assay developed in the present study compared to culture were 100 and 73%, and to conventional PCR with agarose gel and/or TRF detection 93 and 96%, respectively. The real-time PCR assay was found to be rapid, easy to use, and sensitive in detecting and quantifying pneumococci.

Predicting the development and outcome of otitis media by tympanometry

OBJECTIVE

Identification of children with high risk of development or prolongation of otitis media would be highly useful in clinical practice. In this study, tympanometry was assessed for its capability in predicting development and resolution of acute otitis media (AOM).

METHODS

Visits of 329 children followed in the Finnish Otitis Media Cohort Study from 2 to 24 months of age were evaluated for this report. Tympanometry was routinely performed on all children during their visits to a special study clinic. Adjacent consecutive visits were used for analysis of development and resolution of middle ear fluid (MEF) between the visits. Descriptive analysis utilized all data obtained during the longitudinal follow-up; confirmatory statistical analysis was performed on data of one randomly selected visit per subject to ensure independence of observations. Presence of MEF at the second visit was used as the outcome.

RESULTS

Negative tympanometric peak pressure (<-100 daPa) was found to predict the development of otitis media when observed during respiratory infection with no concomitant ear disease. Otitis media developed within 20 days to 40% of children with negative pressure compared with 20% of children without negative pressure. The observed association was confirmed statistically (odds ratio 4.8, 95% confidence interval 2.4-9.6). Poor outcome of AOM at the subsequent follow-up visit 3-5 weeks later was found in 9% of ears with negative pressure tympanogram compared with 24% with initial type B or normal pressure tympanogram during AOM. However, we could not confirm the finding in statistical analysis (odds ratio 0.6, 95% confidence interval 0.2-2.0).

CONCLUSIONS

Profound negative tympanometric peak pressure is a significant marker of increased risk for development of otitis media. Children with negative pressure have to be thoroughly followed for subsequent progress of the respiratory disease and development of otitis media. For the prediction of resolution of AOM, the findings remained inconclusive.

Regular-dose versus high-dose omeprazole in peptic ulcer bleeding: a prospective randomized double-blind study

BACKGROUND

It has been suggested that profound acid inhibition along with endoscopic therapy might prevent rebleeding and reduce mortality in patients with peptic ulcer bleeding. The aim of the study was to test the possible equivalence of a high dose and the regular dose of omeprazole in peptic ulcer bleeding.

METHODS

We performed a prospective randomized double-blind study involving 142 patients with acute peptic ulcer bleeding (Forrest classification I-II: spurting or oozing bleeding, non-bleeding visible vessel, clot and black base). One-hundred-and-two (71.8%) patients received endoscopic treatment (adrenaline injection and/or heater probe) in pre-entry. Patients were randomly assigned to receive the regular dose of omeprazole intravenously (20 mg once a day for 3 days, i.e. 60 mg/72 h) or a high dose of omeprazole (80 mg bolus + 8 mg/h for 3 days, i.e. 652 mg/72 h). Rebleeding, surgery and death were the outcome measures.

RESULTS

Six (8.2%) of the 73 patients receiving the regular dose of omeprazole and 8 (11.6%) of the 69 patients receiving the high dose of omeprazole rebled (P = 0.002 for equivalence, equivalence limit 0.15). Three (4.1%) of the former patients and 5 (7.2%) of the latter group underwent surgery. Four (5.5%) patients in the regular-dose and 2 (2.9%) in the high-dose group died within 30 days.

CONCLUSION

Under the defined tolerance limits, the regular dose of omeprazole is as successful as a high dose in preventing peptic ulcer rebleeding.

Negative pressure tympanograms in children less than 2 years of age--different bacterial findings in otitis media by tympanometric results

OBJECTIVE

The interpretation of negative pressure tympanograms as indicators of the presence of middle ear fluid has been ambiguous. Our purpose was to assess the occurrence and implications of negative pressure tympanograms and to study their association with bacterial pathogens in otitis media.

METHODS

Altogether 329 infants were enrolled at a well-baby clinic for the Finnish Otitis Media Cohort Study, a longitudinal prospective cohort study. The children were closely followed in a special study clinic from 2 to 24 months of age for respiratory diseases, especially acute otitis media. Children were examined at the study clinic with tympanometry and pneumatic otoscopy whenever visiting the study clinic for respiratory disease. Myringotomy with aspiration was performed if middle ear fluid was suspected in otoscopy. Occurrence of middle ear fluid in ears with negative pressure tympanograms (less than -100 daPa) was assessed. Nested case control design matched by visit type (acute or follow-up visit) and month of visit was used for analysis of association of bacterial pathogens and tympanometric results.

RESULTS

Middle ear fluid was encountered in 15% of ears with negative tympanometric peak pressure, a lower proportion than described previously. In otitis media with a negative tympanometric peak pressure, 71% of bacterial cultures remained negative for the main pathogens, compared to 36% in matched controls (P<0.001). Especially Streptococcus pneumoniae but also Haemophilus influenzae were rarely found in samples from negative pressure ears. Moraxella catarrhalis was equally often found.

CONCLUSIONS

Negative pressure tympanogram is a poor indicator for the presence of middle ear fluid. Furthermore, if otitis media is diagnosed with negative tympanometric peak pressure negative middle ear bacterial culture for the main pathogens is highly probable. Expectant follow-up might be more appropriate than routine antibiotic treatment.

Normative values for tympanometry in 7- and 24-month-old children

The objective was to determine normative values for tympanometric variables for 7- and 24-month-old children and to assess the effect of various factors on these variables. Tympanometry was performed at scheduled health visits at 7 and 24 months of age on children recruited to a prospective vaccine efficacy trial (n=2497 children at enrolment). Tympanograms obtained successfully from healthy ears with no recent otitis media were analysed. Normative values for static acoustic admittance (SAA), tympanometric peak pressure (TPP) and tympanometric width (TW) were calculated. The mean SAA was 0.25 cm3 at the 7-month visit compared to 0.34 cm3 at the 24-month visit. The TW decreased and TPP remained unchanged with age. Higher SAA values were found in boys. A history of recurrent acute otitis media and history of tympanostomy tubes were found to increase SAA and decrease TW at 24 months. In conclusion, age-specific normative values for interpretation of SAA and TW are necessary.

Interrater agreement on tympanometry in infants

Two-hundred and forty-two tympanograms of infants were interpreted according to a standard operating procedure independently by an audiologist and ten study doctors from the Finnish Otitis Media Vaccine Trial. The interrater agreement among the study doctors according to Kappa index was excellent (kappa = 0.80). The agreement was significantly better on curves taken during pre-scheduled healthy visits than during sick visits due to respiratory infection (p < 0.001). In addition concurrent knowledge of the clinical ear status significantly improved the agreement on abnormal curves (flat B-curves and failed F-curves, p < 0.001). The clinical differences between the groups were minor. The age of the infant had no effect on interpretation. The agreement between the audiologist and the study doctors was also excellent (kappa = 0.77). Excellent agreement can be achieved in infant tympanometry through adequate instruction and training.

Efficacy of a pneumococcal conjugate vaccine against acute otitis media

BACKGROUND

Ear infections are a common cause of illness during the first two years of life. New conjugate vaccines may be able to prevent a substantial portion of cases of acute otitis media caused by Streptococcus pneumoniae.

METHODS

We enrolled 1662 infants in a randomized, double-blind efficacy trial of a heptavalent pneumococcal polysaccharide conjugate vaccine in which the carrier protein is the nontoxic diphtheria-toxin analogue CRM197. The children received either the study vaccine or a hepatitis B vaccine as a control at 2, 4, 6, and 12 months of age. The clinical diagnosis of acute otitis media was based on predefined criteria, and the bacteriologic diagnosis was based on a culture of middle-ear fluid obtained by myringotomy.

RESULTS

Of the children who were enrolled, 95.1 percent completed the trial. With the pneumococcal vaccine, there were more local reactions than with the hepatitis B vaccine but fewer than with the combined whole-cell diphtheria-tetanus-pertussis and Haemophilus influenzae type b vaccine that was administered simultaneously. There were 2596 episodes of acute otitis media during the follow-up period between 6.5 and 24 months of age. The vaccine reduced the number of episodes of acute otitis media from any cause by 6 percent (95 percent confidence interval, -4 to 16 percent [the negative number indicates a possible increase in the number of episodes]), culture-confirmed pneumococcal episodes by 34 percent (95 percent confidence interval, 21 to 45 percent), and the number of episodes due to the serotypes contained in the vaccine by 57 percent (95 percent confidence interval, 44 to 67 percent). The number of episodes attributed to serotypes that are cross-reactive with those in the vaccine was reduced by 51 percent, whereas the number of episodes due to all other serotypes increased by 33 percent.

CONCLUSIONS

The heptavalent pneumococcal polysaccharide-CRM197 conjugate vaccine is safe and efficacious in the prevention of acute otitis media caused by the serotypes included in the vaccine.

Diagnostic value of tympanometry in infants in clinical practice

One hundred and twenty-one visits of 58 infants (2-11 months of age) were evaluated in the Finnish Otitis Media Vaccine Trial. Infants were examined with tympanometry (Grason-Stadler GSI 38 Autotymp) and pneumatic otoscopy by one study doctor. Diagnosis of otitis media was verified by myringotomy in 74% of cases. Tympanometry was technically successful in 94% of ears. The success rate was statistically significantly higher (P < 0.05) among infants less than 7 months of age than those above 7 months. The sensitivity of tympanometry (type B) to detect ears with middle ear fluid was 0.70 and the specificity 0.98 with a positive predictive value of 0.93 and negative predictive value of 0.94. The sensitivity was somewhat lower in the younger age group (0.61); specificity and positive and negative predictive values were good in both age groups. The high success rate and high negative and positive predictive values of tympanometry make it a useful aid for assuring the correct diagnosis of otitis media in infants in routine clinical practice.

Acute upper gastrointestinal haemorrhage in Central Finland Province, Finland, and in Tartu County, Estonia

BACKGROUND AND AIMS

A comparative study of the epidemiology of acute upper gastrointestinal haemorrhage (UGIH) was carried out in Central Finland province (CF), Finland, and in Tartu county (TC), Estonia.

PATIENTS AND METHODS

All patients from CF and TC aged > or = 15 who were treated in the Central Hospital of Central Finland and in Tartu University Hospital for UGIH, entered the prospective study during 1 August 1992-31 July 1994. Altogether 298 patients (198 men, 100 women) were treated in CF and 270 patients (159 men, 104 women) in TC.

RESULTS AND CONCLUSIONS

The overall incidence of UGIH was 68.3/100,000 adults per year in CF and 98.6 in TC. The incidence increased considerably with age: from 3.1 in those aged 20-29 to 314.1 in those > or = 80 in CF, and from 13.2 to 299.1 in TC, respectively. Incidence rates were twice as low in younger age groups in CF compared to TC, almost equalized in those > or = 60 and became even higher in those > or = 80. 63% of the patients (55% men, 79% women) in CF and 49% (35% men, 70% women) in TC were > or = 60. NSAID use before UGIH was equally common (46%) in both regions. Peptic ulcer accounted for over 50% of UGIH cases both in CF and TC. Mortality rate was 8.1% in CF and 9.9% in TC. The main epidemiological differences between the regions are the lower overall incidence of UGIH, due to the lower incidence of haemorrhage in the younger age groups, and the higher proportion of the elderly patients in CF compared to TC.

Primary gastrointestinal non-Hodgkin's lymphoma. A population based study in central Finland in 1975-1993

Gastrointestinal lymphomas have been uncommon, but the frequency of their predisposing conditions is increasing. The objective of the present study is to determine the frequency of gastrointestinal lymphomas in the area of central Finland as well as the influence of clinical features and therapeutical approaches on the survival of these patients. All samples of gastrointestinal non-Hodgkin's lymphomas diagnosed of patients living in the province of central Finland in 1975-1993 were re-examined. In central Finland the mean annual frequency of new gastrointestinal lymphomas was 10/1000000 in 1975-1984 and 16.0/1000000 in 1985-1993. The total incidence of gastrointestinal lymphomas in Finland adjusted for age to the world standard population was 12.5/1000000 in 1992. Two patients with peripheric T-cell lymphoma had a coeliac disease. Other predisposing conditions were not found. The stage of distribution of the lymphoma (p < 0.01) and radicality of the surgery (p < 0.01) were the most influencing factors on the survival of these patients. In conclusion the early distinction of gastrointestinal lymphomas is vital because of an increasing frequency of predisposing factors and a better prognosis due to new combination therapies.

Biofeedback therapy in rectal prolapse patients

PURPOSE

The aim of the study was to evaluate the effect of perioperative biofeedback training on postoperative continence in patients with rectal prolapse.

METHODS

Thirty-six consecutive patients were operated on between 1987 and 1993. Twenty-nine could be traced for reexamination. Four were excluded because of a recurring prolapse. Anal manometry, assessment of rectoanal sensation, and surface electromyography were performed during the reexamination. From 1987 to 1991, no perioperative biofeedback training was given (Group 1, n = 14). Since the beginning of 1992, incontinent patients were given biofeedback training (Group 2, n = 11).

RESULTS

Continence scores improved in both study groups. Both study groups had equally low resting pressures compared with Group 3 (controls) (30.6 +/- 14.9 vs. 53.0 +/- 11.9 mmHg; P < 0.001). Anal resting pressure correlated with postoperative continence score, whereas contractile pressures did not (r = -0.5,P < 0.05, and r = -0.3, p = not significant, respectively).

CONCLUSION

Biofeedback therapy can improve the function of external sphincter; however, the most important reason for postoperative incontinence in rectal prolapse patients is low resting pressure that cannot be corrected by biofeedback therapy.

Endotoxaemia and acute pancreatitis: correlation between the severity of the disease and the anti-enterobacterial common antigen antibody titre

Enterobacterial common antigen is a highly immunogenic component of the Gram negative bacterial cell wall that is common to all enteric bacteria. In the present study, the humoral antibody response against enteric bacteria was investigated by measuring antibodies to enterobacterial common antigen in paired serum samples in 38 patients with acute pancreatitis and in 31 healthy subjects. In mild pancreatitis (11 patients), no changes in anti-enterobacterial common antigen titres were observed as compared with healthy controls. Nine of the 10 patients had a significant increase (greater than or equal to 8 times) in anti-enterobacterial common antigen titres during the disease. Similarly, in patients with fulminant (haemorrhagic) pancreatitis who survived, a significant increase in anti-enterobacterial common antigen titres occurred during the course of the disease (in nine of the 11 patients). Paradoxically, only one of the six patients with fulminant pancreatitis with fatal outcome showed a significant increase in his anti-enterobacterial common antigen titre. The results suggest that Gram negative bacterial components escape into the systemic circulation in acute pancreatitis. This may have pathophysiologic significance in this disease.

Ornidazole and anaerobic bacteria: in vitro sensitivity and effects on wound infections after appendectomy

The sensitivities of 68 clinical isolates of Bacteroides fragilis, 18 of Clostridium perfringens, and 11 of other Clostridium species were tested against ornidazole alone and in combination with ampicillin and gentamicin. A concentration of 3.1 microgram of ornidazole/ml inhibited 98% of the strains of B. fragilis, with greater sensitivity when ampicillin and gentamicin were also present. A concentration of 6.2 microgram of ornidazole/ml inhibited 16 of 18 strains of C. perfringens and all 11 strains of other Clostridium species. Concentrations in serum and tissue were determined after intravenous infusion of 500 mg of ornidazole 15 min prior to appendectomy. During the operation the concentration in serum was 7.90 +/- 0.57 microgram/ml, and in appendix tissue, 5.26 +/- 0.60 microgram/g. In the series of 200 patients undergoing appendectomy, six patients treated with ornidazole and 12 patients treated with placebo developed a wound infection. In patients with perforated appendix, the rate of wound infection was 7.1% in those given ornidazole and 63.6% in those given placebo (P = 0.004). Not a single B. fragilis was isolated from appendix swabs or wound exudates after prophylaxis with ornidazole.

Radiological assessment of nipple-valve insufficienty in Kock's continent reservoir ileostomy

In a series of 51 continent reservoir ileostomies nipple-valve insufficiency developed in 15 patients who were examined radiographically to find the cause for the loss of continency. The radiological diagnosis was confirmed at reoperation. The causes for nipple-valve insufficiency were a total or partial disappearance of the nipple-valve by sliding of the invaginate (7 cases) and dislocation of an undamaged nipple out of the reservoir (8 cases). In these groups the radiological diagnosis was compatible with the operative findings in all but one case. At reoperation a fistula in the nipple-valve was found in 3 cases, but in no instance had this been diagnosed radiologically. A correct preoperative diagnosis is valuable, especially in cases of dislocation, where a danger exists that the real mechanism of valve insufficiency may remain obscure at operation.

Antibiotics in acute cholecystitis

In 460 cholecystectomies performed for acute cholecystitis 215 (47%) positive gallbladder bile cultures were obtained. In 73% of emergency operations bacteria were recovered, in 48% of early operations (p less than 0.001) and in 29% of late operations (p less than 0.001). In vitro concentrations of 8-16 mcg/ml of ampicillin or cephalothin inhibited in most cases the growth of E. coli, Klebsiella and Enterococci, which comprised 75% of all strains isolated. One hour after intravenous infusion of 1 g ampicillin the mean serum level was 21 mcg/ml, the mean common duct level 16 mcg/ml and the mean gallbladder bile level 4.4 mcg/ml. In acute cholecystitis 2 g cephalothin gave mean concentrations of 14, 8, and 1.2 mcg/ml. Most of these patients had cystic duct obstruction both on intravenous cholegraphy and during operation. Control patients with patent cystic ducts who received ampicillin had mean gallbladder and common duct bile levels of 47 and 56 mcg/ml, and those receiving cephalothin 23 and 28 mcg/ml. It appears that adequate gallbladder bile concentrations of antibiotics are not attainable in acute cholecystitis because of the obstruction to the bile flow. The favourable results of prophylactic antibiotic treatment in reducing septic complications seem to depend more on adequate serum and tissue concentrations than on the concentration of antibiotics in the bile.

Kock's continent ileostomy: results of 51 operations and experiences with correction of nipple-valve insufficiency

Fifty-one Kock's continent reservoir ileostomies were performed over a 4-year period. Immediate postoperative complications included 2 perforations of the reservoir, causing the death of 1 patient, 4 faecal fistulas and 8 intestinal obstructions. After a follow-up of more than 3 years in 22 cases, of 1-3 years in 21 cases and of less than 1 year in 8 cases an excellent functional result was attained after the first operation in 31 cases. Fifteen patients had to undergo reoperation owing to leakage of gas and bowel contents and difficulties in catheterization. Reoperation revealed three different causes of nipple insufficiency: total or partial sliding of the invaginate in 6 cases, dislocation of the nipple out of the reservoir in 6 cases and a fistula at the base of the nipple in 3 cases. Correction of the nipple-valve was performed using a modified invagination technique. After reoperation an excellent functional result was attained in 12 out of 15 cases. Thus, the functional result in the whole series was excellent in 43 patients.

The symptoms of nipple-valve insufficiency appeared in most of the cases during the first 3-6 months post-operatively. Since there is a good chance that reoperation will correct the failure, the procedure should be carried out without delay after the appearance of disturbance in nipple-valve function.