Pelvic floor imaging in asymptomatic subjects

AIM

The aim of this work was to determine the range of normal imaging features during total pelvic floor ultrasound (TPFUS) (transperineal, transvaginal, endovaginal and endoanal) and defaecation MRI (dMRI).

METHOD

Twenty asymptomatic female volunteers (mean age 36.5 years) were prospectively investigated with dMRI and TPFUS. Subjects were screened with symptom questionnaires (ICIQ-B, St Mark's faecal incontinence score, obstructed defaecation syndrome score, ICIQ-V, BSAQ). dMRI and TPFUS were performed and interpreted by blinded clinicians according to previously published methods.

RESULTS

The subjects comprised six parous and 14 nulliparous women, of whom three were postmenopausal. There were three with a rectocoele on both modalities and one with a rectocoele on dMRI only. There was one with intussusception on TPFUS. Two had an enterocoele on both modalities and one on TPFUS only. There were six with a cystocoele on both modalities, one on dMRI only and one on TPFUS only. On dMRI, there were 12 with functional features. Four also displayed functional features on TPFUS. Two displayed functional features on TPFUS only.

CONCLUSION

This study demonstrates the presence of abnormal findings on dMRI and TPFUS without symptoms. There was a high rate of functional features on dMRI. This series is not large enough to redefine normal parameters but is helpful for appreciating the wide range of findings seen in health.

Pelvic floor investigations for anal incontinence: Are they useful to predict outcomes from conservative treatment?

AIMS

There are several options for treating anal incontinence (AI), with limited success rate in long-term follow-up. Patients' selection is important to avoid unnecessary investigations and therapies. The aim of this review is to assess the utility of pelvic floor investigations to predict success from conservative treatment in AI.

METHODS

Baseline demographics, severity scores, and pelvic floor investigations of 490 patients with AI symptoms were retrospectively reviewed. Patient-reported outcomes were used to define success of conservative treatment.

RESULTS

Bivariate analysis showed that gender, St Mark's incontinence score, Bowel continence and quality of life domains of International Consultation on Incontinence Modular Questionnaire-Bowel symptoms score, Bristol stool chart, anal squeeze pressure, enterocoele, leak of contrast at rest, and dyssynergia in defecography were associated with patient's outcomes from conservative treatment (p < 0.05). Multivariate analysis showed that only the Bowel continence score was an independent predictor of patient's success with treatment.

CONCLUSIONS

Pelvic floor investigations are of limited value to predict success of conservative treatment and they should be reserved for patients who fail noninvasive management and might require surgical intervention.

Improving Multidisciplinary Team Working to Support Integrated Care for People with Frailty Amidst the COVID-19 Pandemic

Multidisciplinary team (MDT) working is essential to optimise and integrate services for people who are frail. MDTs require collaboration. Many health and social care professionals have not received formal training in collaborative working. This study investigated MDT training designed to help participants deliver integrated care for frail individuals during the Covid-19 pandemic. Researchers utilised a semi-structured analytical framework to support observations of the training sessions and analyse the results of two surveys designed to assess the training process and its impact on participants knowledge and skills. 115 participants from 5 Primary Care Networks in London attended the training. Trainers utilised a video of a patient pathway, encouraged discussion of it, and demonstrated the use of evidence-based tools for patient needs assessment and care planning. Participants were encouraged to critique the patient pathway, reflect on their own experiences of planning and providing patient care. 38% of participants completed a pre-training survey, 47% a post-training survey. Significant improvement in knowledge and skills were reported including understanding roles in contributing to MDT working, confidence to speak in MDT meetings, using a range of evidence-based clinical tools for comprehensive assessment and care planning. Greater levels of autonomy, resilience, and support for MDT working were reported. Training proved effective; it could be scaled up and adopted to other settings.

The association between levator plate integrity and pelvic floor defaecatory dysfunction

AIMS

Levator ani deficiency has been implicated in anterior pelvic floor pathology but its association with pelvic floor defaecatory dysfunction is less clear. The aim was to examine the relationship of levator ani deficiency with anatomical abnormalities (rectocoele, intussusception, enterocoele, perineal descent) and patient symptoms (bowel, vagina) in patients with pelvic floor defaecatory dysfunction.

METHODS

The prospective observational case series of 223 women presenting to a tertiary colorectal pelvic floor unit with defaecatory dysfunction. Each underwent assessment with symptom severity and quality of life (QoL) scores, integrated total pelvic floor ultrasound (PFUS) (transvaginal, transperineal) and defaecation proctography (DP). Rectocoele, intussusception, enterocoele and perineal descent were assessed on both. Levator ani deficiency was scored using endovaginal ultrasound (score 0-18; mild [0-6], moderate [>6-12], severe [>12-18]).

RESULTS

The proportion of patients with rectocoele, enterocoele, and intussusception increased with increasing levator ani damage (mild, moderate, severe). There was a weakly positive correlation between size of rectocoele and levator ani deficiency. On PFUS, there was a weakly positive correlation between severity of intussusception and enterocoele with levator ani deficiency. On DP, there was a weakly positive correlation between perineal descent and levator ani deficiency. There was no association between bowel symptom and QoL scores and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency.

CONCLUSIONS

Anatomical abnormalities which are implicated in pelvic floor defaecatory dysfunction (rectocoele, intussusception, enterocoele, perineal descent) were associated with worsening levator ani deficiency. There was no association between bowel symptoms and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency.

Total pelvic floor ultrasound can reliably predict long-term treatment outcomes for patients with pelvic floor defaecatory dysfunction

AIM

Integrated total pelvic floor ultrasound (TPFUS) may provide an alternative to defaecation proctography (DP) in decision making and treatment planning for patients with pelvic floor defaecatory dysfunction (PFDD). This study evaluates the use of TPUS as a screening tool, and its likelihood to predict long-term treatment outcomes.

METHODS

Two blinded clinicians reviewed 100 women who had historically presented to a tertiary referral colorectal unit with PFDD from October 2014 to April 2015. The clinical history of the patients together with TPFUS or DP results were used to decide on main impression, treatment plan, likelihood of surgery and certainty of plan. These were compared to the actual treatment received six months later and again after a median follow-up of 68 months (range 48-84).

RESULTS

A total of 82 patients were treated with biofeedback only and 18 also underwent surgery. There were no complications in any of the patients who had surgery. When compared with the actual treatment received, 99 of the 100 of the TPFUS group would have been treated appropriately. The number of false positives for surgical treatment was lower with TPFUS compared to DP. Clinician confidence in the overall decision was significantly higher after review with DP.

CONCLUSIONS

TPFUS is a reliable assessment tool for PFDD. It can identify patients who can go straight to biofeedback and is just as good as DP at predicting likelihood of surgery. We might be able to rely on TPFUS more significantly in the future, even for surgical planning.

Patient pathway in a tertiary referral pelvic floor unit: Telephone triage assessment clinic

BACKGROUND

To meet the increasing demands for colorectal pelvic floor services, a dedicated telephone triage assessment clinic (TTAC) was set up to establish a more efficient pathway, and reduce waiting times and patient's visits to the hospital. The primary aim of this study was to review TTAC in patients suffering from pelvic floor dysfunction and assess its feasibility. Secondary aims include measurement of waiting times for TTAC, main presenting complaints, and main treatment outcomes, including the need for review by a consultant surgeon.

METHODS

Review of data collected retrospectively in a single tertiary referral center collected from an institutional database.

KEY RESULTS

Between January 2016 and October 2017, 1192 patients referred to our pelvic floor unit were suitable for TTAC. Of these, 694 patients had complete records. There were 66 without follow-up after the initial TTAC, leaving 628 patients for analysis. In all, 86% were females and 14% were males, with a mean age of 52 years (range: 18-89). The median waiting time for TTAC was 31 days (range: 0-184). The main presenting complaint during the TTAC was obstructive defecation in 69.4%, fecal incontinence in 28.5%, and rectal prolapse in 2.1%. In our study, 611 patients had conservative management (97.3%), with a median of three sessions per patient (range: 1-16), while 82 patients (13.1%) needed a surgical intervention. Only 223 patients (35.5%) were reviewed by a consultant at some stage during the study period.

CONCLUSIONS AND INFERENCES

To optimize resources, an adequate triage system allowed us to streamline the pathway for each individual patient with pelvic floor dysfunction according to their symptoms and/or test results with the aim of reducing waiting times and expediting treatment.

Is there any association between symptoms and findings on imaging in pelvic floor defaecatory dysfunction? A prospective study

AIM

To compare features on imaging (integrated total pelvic floor ultrasound (transperineal, transvaginal) and defaecation proctography) with bowel, bladder and vaginal symptoms in pelvic floor defaecatory dysfunction.

METHOD

A prospective observational case series of 216 symptomatic women who underwent symptom severity scoring (bowel, bladder and vaginal), integrated total pelvic floor ultrasound and defaecation proctography. Anatomical (rectocele, intussusception, enterocele, cystocele) and functional (co-ordination, evacuation) features were examined.

RESULTS

Irrespective of imaging modality, patients with a rectocele had higher International Consultation on Incontinence Modular Questionnaire - Vaginal Symptoms (ICIQ-VS) scores than patients without. On integrated total pelvic floor ultrasound, ICIQ-VS quality of life scores were higher in those with a rectocele. There was a higher International Consultation on Incontinence Modular Questionnaire - Bowel Symptoms (ICIQ-BS) bowel pattern score in those with a rectocele, and a lower ICIQ-BS bowel pattern and sexual impact score in those with intussusception. Poor co-ordination was associated with increased ICIQ-BS bowel control scores and obstructed defaecation symptom scores. On defaecation proctography, ICIQ-VS symptom scores were lower in patients with poor co-ordination.

CONCLUSION

Patients with a rectocele on either imaging modality may have qualitative vaginal symptoms on assessment. In patients with bowel symptoms but no vaginal symptoms, it is not possible to predict which anatomical abnormalities will be present on imaging.

Erratum: Observation of D^{0} Meson Nuclear Modifications in Au+Au Collisions at sqrt[s_{NN}]=200 GeV [Phys. Rev. Lett. 113, 142301 (2014)]

This corrects the article DOI: 10.1103/PhysRevLett.113.142301.

Randomized controlled trial of honey versus mupirocin to decolonize patients with nasal colonization of meticillin-resistant Staphylococcus aureus

BACKGROUND

Mupirocin is used specifically for the eradication of nasal meticillin-resistant Staphylococcus aureus (MRSA), but increasing mupirocin resistance restricts its repeated use. The antibacterial effects of manuka honey have been established in vitro; antibacterial activity of other honeys has also been reported.

AIM

To describe the learning experience from a randomized controlled trial (RCT) comparing the efficacy of medical-grade honey (MGH) with mupirocin 2% for the eradication of nasal MRSA.

METHODS

Patients colonized in the nose with MRSA and age ≥18 years were recruited. Participants received either one or two courses of MGH or mupirocin 2%, three times per day for five consecutive days.

FINDINGS

The proportion of patients who were decolonized after one or two courses of treatment was not significantly different between MGH [18/42; 42.8%; 95% confidence interval (CI): 27.7-59.0] and mupirocin 2% (25/44; 56.8%; 95% CI: 41.0-71.7). Non-nasal MRSA colonization was significantly associated with persistent nasal colonization (odds ratio: 5.186; 95% CI: 1.736-5.489; P = 0.003). The rate of new acquisition of mupirocin resistance was 9.75%.

CONCLUSION

Although not significant, a decolonization rate of 42.8% for MGH was impressive. Our findings suggest that this strategy, which has the potential to combat antimicrobial resistance, should be assessed in similar but larger studies.

Integrated total pelvic floor ultrasound in pelvic floor defaecatory dysfunction

AIM

Imaging for pelvic floor defaecatory dysfunction includes defaecation proctography. Integrated total pelvic floor ultrasound (transvaginal, transperineal, endoanal) may be an alternative. This study assesses ultrasound accuracy for the detection of rectocele, intussusception, enterocele and dyssynergy compared with defaecation proctography, and determines if ultrasound can predict symptoms and findings on proctography. Treatment is examined.

METHOD

Images of 323 women who underwent integrated total pelvic floor ultrasound and defaecation proctography between 2011 and 2014 were blindly reviewed. The size and grade of rectocele, enterocele, intussusception and dyssynergy were noted on both, using proctography as the gold standard. Barium trapping in a rectocele or a functionally significant enterocele was noted on proctography. Demographics and Obstructive Defaecation Symptom scores were collated.

RESULTS

The positive predictive value of ultrasound was 73% for rectocele, 79% for intussusception and 91% for enterocele. The negative predictive value for dyssynergy was 99%. Agreement was moderate for rectocele and intussusception, good for enterocele and fair for dyssynergy. The majority of rectoceles that required surgery (59/61) and caused barium trapping (85/89) were detected on ultrasound. A rectocele seen on both transvaginal and transperineal scanning was more likely to require surgery than if seen with only one mode (P = 0.0001). If there was intussusception on ultrasound the patient was more likely to have surgery (P = 0.03). An enterocele visualized on ultrasound was likely to be functionally significant on proctography (P = 0.02). There was, however, no association between findings on imaging and symptoms.

CONCLUSION

Integrated total pelvic floor ultrasound provides a useful screening tool for women with defaecatory dysfunction such that defaecatory imaging can avoided in some.

Total pelvic floor ultrasound for pelvic floor defaecatory dysfunction: a pictorial review

Total pelvic floor ultrasound is used for the dynamic assessment of pelvic floor dysfunction and allows multicompartmental anatomical and functional assessment. Pelvic floor dysfunction includes defaecatory, urinary and sexual dysfunction, pelvic organ prolapse and pain. It is common, increasingly recognized and associated with increasing age and multiparity. Other options for assessment include defaecation proctography and defaecation MRI. Total pelvic floor ultrasound is a cheap, safe, imaging tool, which may be performed as a first-line investigation in outpatients. It allows dynamic assessment of the entire pelvic floor, essential for treatment planning for females who often have multiple diagnoses where treatment should address all aspects of dysfunction to yield optimal results. Transvaginal scanning using a rotating single crystal probe provides sagittal views of bladder neck support anteriorly. Posterior transvaginal ultrasound may reveal rectocoele, enterocoele or intussusception whilst bearing down. The vaginal probe is also used to acquire a 360° cross-sectional image to allow anatomical visualization of the pelvic floor and provides information regarding levator plate integrity and pelvic organ alignment. Dynamic transperineal ultrasound using a conventional curved array probe provides a global view of the anterior, middle and posterior compartments and may show cystocoele, enterocoele, sigmoidocoele or rectocoele. This pictorial review provides an atlas of normal and pathological images required for global pelvic floor assessment in females presenting with defaecatory dysfunction. Total pelvic floor ultrasound may be used with complementary endoanal ultrasound to assess the sphincter complex, but this is beyond the scope of this review.

Precision Measurement of the Longitudinal Double-Spin Asymmetry for Inclusive Jet Production in Polarized Proton Collisions at sqrt[s]=200 GeV

We report a new measurement of the midrapidity inclusive jet longitudinal double-spin asymmetry, A_{LL}, in polarized pp collisions at center-of-mass energy sqrt[s]=200  GeV. The STAR data place stringent constraints on polarized parton distribution functions extracted at next-to-leading order from global analyses of inclusive deep-inelastic scattering (DIS), semi-inclusive DIS, and RHIC pp data. The measured asymmetries provide evidence at the 3σ level for positive gluon polarization in the Bjorken-x region x>0.05.

ΛΛ Correlation function in Au+Au collisions at √[S(NN)]=200 GeV

We present ΛΛ correlation measurements in heavy-ion collisions for Au+Au collisions at sqrt[s_{NN}]=200  GeV using the STAR experiment at the Relativistic Heavy-Ion Collider. The Lednický-Lyuboshitz analytical model has been used to fit the data to obtain a source size, a scattering length and an effective range. Implications of the measurement of the ΛΛ correlation function and interaction parameters for dihyperon searches are discussed.

Observation of D0 meson nuclear modifications in Au+Au collisions at sqrt[s(NN)] = 200 GeV

We report the first measurement of charmed-hadron (D(0)) production via the hadronic decay channel (D(0) → K(-) + π(+)) in Au+Au collisions at sqrt[s(NN)] = 200 GeV with the STAR experiment. The charm production cross section per nucleon-nucleon collision at midrapidity scales with the number of binary collisions, N(bin), from p+p to central Au+Au collisions. The D(0) meson yields in central Au + Au collisions are strongly suppressed compared to those in p+p scaled by N(bin), for transverse momenta p(T) > 3 GeV/c, demonstrating significant energy loss of charm quarks in the hot and dense medium. An enhancement at intermediate p(T) is also observed. Model calculations including strong charm-medium interactions and coalescence hadronization describe our measurements.

Beam energy dependence of moments of the net-charge multiplicity distributions in Au+Au collisions at RHIC

We report the first measurements of the moments--mean (M), variance (σ(2)), skewness (S), and kurtosis (κ)--of the net-charge multiplicity distributions at midrapidity in Au+Au collisions at seven energies, ranging from sqrt[sNN]=7.7 to 200 GeV, as a part of the Beam Energy Scan program at RHIC. The moments are related to the thermodynamic susceptibilities of net charge, and are sensitive to the location of the QCD critical point. We compare the products of the moments, σ(2)/M, Sσ, and κσ(2), with the expectations from Poisson and negative binomial distributions (NBDs). The Sσ values deviate from the Poisson baseline and are close to the NBD baseline, while the κσ(2) values tend to lie between the two. Within the present uncertainties, our data do not show nonmonotonic behavior as a function of collision energy. These measurements provide a valuable tool to extract the freeze-out parameters in heavy-ion collisions by comparing with theoretical models.

Measurement of longitudinal spin asymmetries for weak boson production in polarized proton-proton collisions at RHIC

We report measurements of single- and double-spin asymmetries for W^{±} and Z/γ^{*} boson production in longitudinally polarized p+p collisions at sqrt[s]=510  GeV by the STAR experiment at RHIC. The asymmetries for W^{±} were measured as a function of the decay lepton pseudorapidity, which provides a theoretically clean probe of the proton's polarized quark distributions at the scale of the W mass. The results are compared to theoretical predictions, constrained by polarized deep inelastic scattering measurements, and show a preference for a sizable, positive up antiquark polarization in the range 0.05<x<0.2.

Beam-energy dependence of charge separation along the magnetic field in Au+Au collisions at RHIC

Local parity-odd domains are theorized to form inside a quark-gluon plasma which has been produced in high-energy heavy-ion collisions. The local parity-odd domains manifest themselves as charge separation along the magnetic field axis via the chiral magnetic effect. The experimental observation of charge separation has previously been reported for heavy-ion collisions at the top RHIC energies. In this Letter, we present the results of the beam-energy dependence of the charge correlations in Au+Au collisions at midrapidity for center-of-mass energies of 7.7, 11.5, 19.6, 27, 39, and 62.4 GeV from the STAR experiment. After background subtraction, the signal gradually reduces with decreased beam energy and tends to vanish by 7.7 GeV. This implies the dominance of hadronic interactions over partonic ones at lower collision energies.

Dielectron mass spectra from Au+Au collisions at √[s(NN)]=200 GeV

We report the STAR measurements of dielectron (e(+)e(-)) production at midrapidity (|y(ee)|<1) in Au+Au collisions at √[s(NN)]=200  GeV. The measurements are evaluated in different invariant mass regions with a focus on 0.30-0.76 (ρ-like), 0.76-0.80 (ω-like), and 0.98-1.05 (ϕ-like)   GeV/c(2). The spectrum in the ω-like and ϕ-like regions can be well described by the hadronic cocktail simulation. In the ρ-like region, however, the vacuum ρ spectral function cannot describe the shape of the dielectron excess. In this range, an enhancement of 1.77±0.11(stat)±0.24(syst)±0.33(cocktail) is determined with respect to the hadronic cocktail simulation that excludes the ρ meson. The excess yield in the ρ-like region increases with the number of collision participants faster than the ω and ϕ yields. Theoretical models with broadened ρ contributions through interactions with constituents in the hot QCD medium provide a consistent description of the dilepton mass spectra for the measurement presented here and the earlier data at the Super Proton Synchrotron energies.

Beam-energy dependence of the directed flow of protons, antiprotons, and pions in Au+Au collisions

Rapidity-odd directed flow (v1) measurements for charged pions, protons, and antiprotons near midrapidity (y=0) are reported in sNN=7.7, 11.5, 19.6, 27, 39, 62.4, and 200 GeV Au+Au collisions as recorded by the STAR detector at the Relativistic Heavy Ion Collider. At intermediate impact parameters, the proton and net-proton slope parameter dv1/dy|y=0 shows a minimum between 11.5 and 19.6 GeV. In addition, the net-proton dv1/dy|y=0 changes sign twice between 7.7 and 39 GeV. The proton and net-proton results qualitatively resemble predictions of a hydrodynamic model with a first-order phase transition from hadronic matter to deconfined matter, and differ from hadronic transport calculations.

Jet-hadron correlations in √[s(NN)]=200 GeV p+p and central Au+Au collisions

Azimuthal angular correlations of charged hadrons with respect to the axis of a reconstructed (trigger) jet in Au+Au and p+p collisions at √[s(NN)]=200  GeV in STAR are presented. The trigger jet population in Au+Au collisions is biased toward jets that have not interacted with the medium, allowing easier matching of jet energies between Au+Au and p+p collisions while enhancing medium effects on the recoil jet. The associated hadron yield of the recoil jet is significantly suppressed at high transverse momentum (pTassoc) and enhanced at low pTassoc in 0%-20% central Au+Au collisions compared to p+p collisions, which is indicative of medium-induced parton energy loss in ultrarelativistic heavy-ion collisions.

Energy dependence of moments of net-proton multiplicity distributions at RHIC

We report the beam energy (sqrt[sNN]=7.7-200  GeV) and collision centrality dependence of the mean (M), standard deviation (σ), skewness (S), and kurtosis (κ) of the net-proton multiplicity distributions in Au+Au collisions. The measurements are carried out by the STAR experiment at midrapidity (|y|<0.5) and within the transverse momentum range 0.4<pT<0.8  GeV/c in the first phase of the Beam Energy Scan program at the Relativistic Heavy Ion Collider. These measurements are important for understanding the quantum chromodynamic phase diagram. The products of the moments, Sσ and κσ2, are sensitive to the correlation length of the hot and dense medium created in the collisions and are related to the ratios of baryon number susceptibilities of corresponding orders. The products of moments are found to have values significantly below the Skellam expectation and close to expectations based on independent proton and antiproton production. The measurements are compared to a transport model calculation to understand the effect of acceptance and baryon number conservation and also to a hadron resonance gas model.

Measurement of J/ψ azimuthal anisotropy in Au+Au collisions at sqrt[s(NN)]=200 GeV

The measurement of J/ψ azimuthal anisotropy is presented as a function of transverse momentum for different centralities in Au+Au collisions at sqrt[s(NN)]=200 GeV. The measured J/ψ elliptic flow is consistent with zero within errors for transverse momentum between 2 and 10 GeV/c. Our measurement suggests that J/ψ particles with relatively large transverse momenta are not dominantly produced by coalescence from thermalized charm quarks, when comparing to model calculations.

Observation of an energy-dependent difference in elliptic flow between particles and antiparticles in relativistic heavy ion collisions

Elliptic flow (v(2)) values for identified particles at midrapidity in Au + Au collisions, measured by the STAR experiment in the beam energy scan at RHIC at sqrt[s(NN)] = 7.7-62.4 GeV, are presented. A beam-energy-dependent difference of the values of v(2) between particles and corresponding antiparticles was observed. The difference increases with decreasing beam energy and is larger for baryons compared to mesons. This implies that, at lower energies, particles and antiparticles are not consistent with the universal number-of-constituent-quark scaling of v(2) that was observed at sqrt[s(NN)] = 200 GeV.

Directed flow of identified particles in Au+Au collisions at √[SNN]=200 GeV at RHIC

STAR's measurements of directed flow (v1) around midrapidity for π±, K±, KS0, p, and p[over ¯] in Au+Au collisions at √[sNN]=200  GeV are presented. A negative v1(y) slope is observed for most of produced particles (π±, K±, KS0, and p[over ¯]). In 5%-30% central collisions, a sizable difference is present between the v1(y) slope of protons and antiprotons, with the former being consistent with zero within errors. The v1 excitation function is presented. Comparisons to model calculations (RQMD, UrQMD, AMPT, QGSM with parton recombination, and a hydrodynamics model with a tilted source) are made. For those models which have calculations of v1 for both pions and protons, none of them can describe v1(y) for pions and protons simultaneously. The hydrodynamics model with a tilted source as currently implemented cannot explain the centrality dependence of the difference between the v1(y) slopes of protons and antiprotons.

Identified hadron compositions in p+p and Au+Au collisions at high transverse momenta at √S(NN)=200 GeV

We report transverse momentum (p(T)≤15  GeV/c) spectra of π(±), K(±), p, p[over ¯], K(S)(0), and ρ(0) at midrapidity in p+p and Au+Au collisions at √S(NN)=200  GeV. Perturbative QCD calculations are consistent with π(±) spectra in p+p collisions but do not reproduce K and p(p[over ¯]) spectra. The observed decreasing antiparticle-to-particle ratios with increasing p(T) provide experimental evidence for varying quark and gluon jet contributions to high-p(T) hadron yields. The relative hadron abundances in Au+Au at p(T)≳8  GeV/c are measured to be similar to the p+p results, despite the expected Casimir effect for parton energy loss.

Strangeness enhancement in Cu-Cu and Au-Au collisions at √S(NN)=200 GeV

We report new STAR measurements of midrapidity yields for the Λ, Λ[over ¯], K(S)(0), Ξ(-), Ξ[over ¯](+), Ω(-), Ω[over ¯](+) particles in Cu+Cu collisions at √S(NN)==200  GeV, and midrapidity yields for the Λ, Λ[over ¯], K(S)(0) particles in Au+Au at √S(NN)==200  GeV. We show that, at a given number of participating nucleons, the production of strange hadrons is higher in Cu+Cu collisions than in Au+Au collisions at the same center-of-mass energy. We find that aspects of the enhancement factors for all particles can be described by a parametrization based on the fraction of participants that undergo multiple collisions.

Vancomycin administration: the impact of multidisciplinary interventions

BACKGROUND

The clinical microbiology team observed that patients were not receiving all prescribed doses of vancomycin. Ward staff was confused about ordering and interpreting vancomycin therapeutic drug monitoring (TDM) levels.

AIM

To audit the incidence of vancomycin dose omission. To implement a series of interventions to improve vancomycin dose administration, and to repeat the audit process to assess these interventions.

METHODS

Three prospective audits were conducted to assess the impact of vancomycin TDM on administration of vancomycin. After the first audit, a number of changes in the TDM process were undertaken. After review of the second audit, a senior pharmacist coordinated ward-based pharmacists in assisting staff to interpret levels, and TDM interpretative charts were designed for drug charts. Following the third audit, feedback to hospital management and a plan for ongoing education were undertaken.

RESULTS

There was a significant reduction in the number of vancomycin doses held inappropriately in the third (10% (78/782) of prescribed doses) when compared to the first audit (16% (161/1007) of doses) (p<0.01). Of doses that were held inappropriately, there was a significant decrease in doses held for no apparent reason in audit 3 (16% (27/170) of prescribed doses) when compared to audit 1 (25% (69/282) of doses) (p<0.05).

CONCLUSIONS

The interventions resulted in a 37.5% reduction in inappropriately held vancomycin doses over a one-year period; 10% of doses are still being held inappropriately. This study highlights the difficulties in identifying barriers to change and changing healthcare worker behaviour.

Investigation of faecal incontinence

Most patients with faecal incontinence require only a full history (information about other predisposing causes) and examination (assessment for faecal impaction and evaluation of sphincter function and structure). When necessary, anorectal physiological studies, endoanal ultrasound and magnetic resonance imaging allow accurate characterization of sphincter function and structure.

Hemodynamic effects of isovolemic hemodilution during descending thoracic aortic cross clamping and lower torso reperfusion

BACKGROUND

Isovolemic hemodilution has been suggested for blood conservation and to improve hemodynamic tolerance to abdominal aortic cross clamping. However, the hemodynamic effects of hemodilution during descending thoracic aortic cross clamping (DAC) have not been established. We evaluated them in anesthetized swine.

METHODS

Hemodilution (n = 7) was produced by the isovolemic exchange of blood for 6% hetastarch to a target hematocrit of 20%. Hematocrit in control pigs (n = 7) remained at 30%. DAC was performed at the T9 level for 45 minutes. During a 60-minute reperfusion period, control pigs were infused with lactated Ringer's solution; shed blood was returned to hemodilution pigs, followed by lactated Ringer's. If hypotension occurred despite left atrial pressure of 10 mm Hg or greater, boluses of phenylephrine were given to keep mean arterial pressure above 60 mm Hg.

RESULTS

Hemodilution caused a marked reduction in hematocrit and in global oxygen delivery (DO2). DAC produced a significant increase in proximal arterial pressure, cardiac index, and DO2 and oxygen consumption (VO2) was markedly reduced in both groups. A significant increase in systemic vascular resistance during DAC occurred only in control pigs. After reperfusion, vascular resistance was significantly lower than baseline in hemodilution pigs, requiring a sixfold greater dose of phenylephrine to avoid hypotension. A lower global DO2 and supply-limited VO2 were also observed in hemodilution pigs.

CONCLUSIONS

Isovolemic hemodilution maintains hemodynamic stability during DAC. During lower torso reperfusion, however, hemodilution caused hemodynamic instability, decreased global DO2, and limited VO2, which may offset its potential benefits.

Pulmonary hypertension and systemic vasoconstriction may offset the benefits of acellular hemoglobin blood substitutes

OBJECTIVE

We tested the hypothesis that the pharmacologic properties of a small volume of alpha alpha-cross-linked hemoglobin (alpha alpha Hb) could effectively resuscitate pigs subjected to hemorrhage.

METHODS

Fourteen pigs hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg for 60 minutes were treated with a 4-mL/kg 2-minute infusion of 10 g/dL alpha alpha Hb or 7 g/dL human serum albumin, an oncotically matched control solution.

RESULTS

The removal of blood (17 +/- 1.5 mL/kg) caused the typical physiologic responses to hemorrhagic hypovolemia. Infusion of alpha alpha Hb restored mean arterial pressure and coronary perfusion pressure, but cardiac output and mixed venous O2 saturation did not improve significantly. Pulmonary arterial pressure and pulmonary vascular resistance increased markedly and were higher than baseline levels after alpha alpha Hb. Infusion of human serum albumin produced only minor hemodynamic changes. Brain blood flow did improve to baseline values after alpha alpha Hb, but was the only tissue to do so. In the human serum albumin group, superior mesenteric artery blood flow recovered to baseline values, whereas brain blood flow did not. Blood flows to other tissues were similar in both groups.

CONCLUSION

Small-volume infusion of alpha alpha Hb restored mean arterial pressure and brain blood flow, but pulmonary hypertension and low peripheral perfusion may offset benefits for trauma patients.

Adjuvant chemotherapy with 5-FU, adriamycin, and mitomycin-C (FAM) versus surgery alone for patients with locally advanced gastric adenocarcinoma: A Southwest Oncology Group study

PURPOSE

To evaluate FAM [5-FU (5-fluorouracil), doxorubicin, mitomycin C] chemotherapy as adjuvant therapy for patients with resected TNM stage I, II, or III gastric carcinoma.

PATIENTS AND METHODS

One hundred ninety-three eligible patients were accrued from 1978 to 1991 in a phase III trial comparing six cycles (1 year) of postoperative FAM chemotherapy with observation only.

RESULTS

The median follow-up on this study was 9.5 years. For all patients, no differences (log-rank analysis) in disease-free survival (p = 0.45) and overall survival (p = 0.57) between FAM therapy (93 cases) and surgery (100 cases) were observed. Quality of surgical resection affected survival irrespective of FAM use. Cases with curative resection, defined in a retrospective review of pathology and surgical reports as cases having no evidence of residual disease in the abdomen and tumor-free margins > 1 cm, had superior survival compared to cases not meeting these requirements (p < 0.001). FAM was well tolerated with 6% (five of 90) of cases demonstrating grade IV hematologic toxicity. There were two drug-related fatalities (one cardiomyopathy, one hematolytic uremic syndrome).

CONCLUSION

FAM is not effective adjuvant therapy for TNM stage I, II, and III patients with resected gastric cancer. Future adjuvant studies must emphasize prospective surgical quality control to assure enrollment of appropriately staged and resected cases and wide participation to assure adequate case accrual over a reasonable period.

Prognostic factors in multiple myeloma

The pretreatment characteristics of 265 multiple myeloma patients treated between 1977 and 1983 were evaluated as potential prognostic factors for survival. Patients whose diagnosis was based on bone marrow plasmacytosis (greater than 30%) were noticed to have poorer survival (P less than 0.001). Although classification of patients according to stage has traditionally been used to identify prognostic groups, differences in survival were noted only between Stage III and Stage I or II patients using one of two common staging systems. Multivariate analysis using Cox's proportional hazards model identified the following prognostic factors in order of importance: plasmacytosis (hazard ratio [HR] = 2.2, 95% confidence interval [CI] = 1.49 to 3.27), hypercalcemia (HR = 1.68, CI = 1.22 to 2.32), hypoalbuminemia (HR = 1.51, CI = 1.15 to 1.99), alkaline phosphatase (HR = 1.62, CI = 1.18 to 2.23), hyperuricemia (HR = 1.46, CI = 1.09 to 1.96), and renal insufficiency (HR = 1.48, CI = 1.08 to 2.04). All patients were followed from 2 to 7.5 years and 130 (49%) survived over 2 years. Logistic regression analysis demonstrated that hyperuricemia, hypoalbuminemia, renal insufficiency, plasmacytosis, gender, alkaline phosphatase, and hypercalcemia were significant predictors of 2-year survival. Knowledge of these factors could be of value in predicting prognosis and planning therapy in patients with multiple myeloma.

Dicentric isochromosome for the long arm of chromosome #17, dic i(17q), in a patient with chronic myelogenous leukemia (CML)

Cytogenetic studies in a 33-year-old male patient with chronic myelogenous leukemia of 7 years duration revealed a so-called i(17q) chromosome marker and other cytogenetic abnormalities during the early phase of blastic crisis which were not present at diagnosis. Careful morphologic examination of this marker using G- and C-banding techniques revealed it to be a dicentric chromosome with a very short intercentromeric area. The fact that the dicentric nature of this marker was not apparent with the conventional Giemsa stain emphasizes the usefulness of the C-banding technique in defining the origin of this important cytogenetic marker.

Delayed hemolytic transfusion reactions. An often-missed entity

Delayed hemolytic transfusion reactions in eight persons were manifested solely or primarily by an apparently unexplained posttransfusion decrease in the hematocrit value. Alloantibodies were eventually found in all eight patients, but were sometimes undetectable for as long as 72 hours after the reaction. This did not preclude the occurrence of a new, acute hemolytic reaction. There were three instances of reversible renal failure complicating the reaction. In two patients, some or all of the antibodies became undetectable after four and nine months. In a third, the indirect antiglobulin reactions became considerably weaker after 12 months. Patients previously sensitized to RBC antigens should have available records inspected and a warning device (wristband or wallet card) provided to help prevent reactions caused by an anamnestic antibody rise.