Presentation, clinical course and complications in trauma patients with concomitant COVID-19 infection

BACKGROUND

This study investigated the impact of COVID-19 infection on hospitalized trauma patients.

METHODS

A retrospective review of hospitalized trauma patients at a level I trauma center was performed from March-December 2020. Data pertaining to patient demographics, presentation and hospital course was compared between COVID positive and negative trauma patients.

RESULTS

There were 4,912 patients and 179 (3.64%) were COVID-19 positive. Demographics and clinical presentation did not differ significantly between those with and without concomitant COVID-19. However, COVID positive trauma patients had higher rates of acute kidney injury (p = 0.016), sepsis (p = 0.016), unplanned intubation (p = 0.002) and unplanned return to the ICU (p = 0.01). The COVID positive cohort also had longer hospital stays (p < 0.01) with no significant difference in mortality.

CONCLUSIONS

In the setting of an ongoing pandemic, awareness of the complications COVID positive trauma patients are predisposed to is important for providers.

Evidence for a time-dependent association between FOLR1 expression and survival from ovarian carcinoma: implications for clinical testing. An Ovarian Tumour Tissue Analysis consortium study

BACKGROUND

Folate receptor 1 (FOLR1) is expressed in the majority of ovarian carcinomas (OvCa), making it an attractive target for therapy. However, clinical trials testing anti-FOLR1 therapies in OvCa show mixed results and require better understanding of the prognostic relevance of FOLR1 expression. We conducted a large study evaluating FOLR1 expression with survival in different histological types of OvCa.

METHODS

Tissue microarrays composed of tumour samples from 2801 patients in the Ovarian Tumour Tissue Analysis (OTTA) consortium were assessed for FOLR1 expression by centralised immunohistochemistry. We estimated associations for overall (OS) and progression-free (PFS) survival using adjusted Cox regression models. High-grade serous ovarian carcinomas (HGSC) from The Cancer Genome Atlas (TCGA) were evaluated independently for association between FOLR1 mRNA upregulation and survival.

RESULTS

FOLR1 expression ranged from 76% in HGSC to 11% in mucinous carcinomas in OTTA. For HGSC, the association between FOLR1 expression and OS changed significantly during the years following diagnosis in OTTA (Pinteraction=0.01, N=1422) and TCGA (Pinteraction=0.01, N=485). In OTTA, particularly for FIGO stage I/II tumours, patients with FOLR1-positive HGSC showed increased OS during the first 2 years only (hazard ratio=0.44, 95% confidence interval=0.20-0.96) and patients with FOLR1-positive clear cell carcinomas (CCC) showed decreased PFS independent of follow-up time (HR=1.89, 95% CI=1.10-3.25, N=259). In TCGA, FOLR1 mRNA upregulation in HGSC was also associated with increased OS during the first 2 years following diagnosis irrespective of tumour stage (HR: 0.48, 95% CI: 0.25-0.94).

CONCLUSIONS

FOLR1-positive HGSC tumours were associated with an increased OS in the first 2 years following diagnosis. Patients with FOLR1-negative, poor prognosis HGSC would be unlikely to benefit from anti-FOLR1 therapies. In contrast, a decreased PFS interval was observed for FOLR1-positive CCC. The clinical efficacy of FOLR1-targeted interventions should therefore be evaluated according to histology, stage and time following diagnosis.

Evidence for a time-dependent association between FOLR1 expression and survival from ovarian carcinoma: implications for clinical testing. An Ovarian Tumour Tissue Analysis consortium study

BACKGROUND

Folate receptor 1 (FOLR1) is expressed in the majority of ovarian carcinomas (OvCa), making it an attractive target for therapy. However, clinical trials testing anti-FOLR1 therapies in OvCa show mixed results and require better understanding of the prognostic relevance of FOLR1 expression. We conducted a large study evaluating FOLR1 expression with survival in different histological types of OvCa.

METHODS

Tissue microarrays composed of tumour samples from 2801 patients in the Ovarian Tumour Tissue Analysis (OTTA) consortium were assessed for FOLR1 expression by centralised immunohistochemistry. We estimated associations for overall (OS) and progression-free (PFS) survival using adjusted Cox regression models. High-grade serous ovarian carcinomas (HGSC) from The Cancer Genome Atlas (TCGA) were evaluated independently for association between FOLR1 mRNA upregulation and survival.

RESULTS

FOLR1 expression ranged from 76% in HGSC to 11% in mucinous carcinomas in OTTA. For HGSC, the association between FOLR1 expression and OS changed significantly during the years following diagnosis in OTTA (Pinteraction=0.01, N=1422) and TCGA (Pinteraction=0.01, N=485). In OTTA, particularly for FIGO stage I/II tumours, patients with FOLR1-positive HGSC showed increased OS during the first 2 years only (hazard ratio=0.44, 95% confidence interval=0.20-0.96) and patients with FOLR1-positive clear cell carcinomas (CCC) showed decreased PFS independent of follow-up time (HR=1.89, 95% CI=1.10-3.25, N=259). In TCGA, FOLR1 mRNA upregulation in HGSC was also associated with increased OS during the first 2 years following diagnosis irrespective of tumour stage (HR: 0.48, 95% CI: 0.25-0.94).

CONCLUSIONS

FOLR1-positive HGSC tumours were associated with an increased OS in the first 2 years following diagnosis. Patients with FOLR1-negative, poor prognosis HGSC would be unlikely to benefit from anti-FOLR1 therapies. In contrast, a decreased PFS interval was observed for FOLR1-positive CCC. The clinical efficacy of FOLR1-targeted interventions should therefore be evaluated according to histology, stage and time following diagnosis.

Abstract T P198: Cerebrovascular Disease Patterns among Emergency Room Admissions in 4070 Consecutive Patients of Haiti

Introduction: No study to date has examined cerebrovascular disease patterns in the country of Haiti. Our objective was to describe the patterns of presentation and outcomes of neurological patients presenting to the emergency room (ER) of a major public hospital in Port-au-Prince.

Methods: After obtaining ethical approvals from institutions in the US and in Haiti, de-identified data on neurologic disease were prospectively collected from patients consecutively admitted to the ER of Hôpital de L’Université d’État d’Haïti (HUEH) from November 2012 to January 2013. Data were collected over a period of 90 days using Microsoft Excel, analyzed with standard statistical analysis and is shown as mean±SD.

Results: Out of 4070 consecutive patients, there were 792 neurological admissions (19%; age 42y±20; 40%man). The diagnosis of stroke accounted for 25% of admissions (age 58y±16; 41%man), while hypertensive encephalopathy accounted for 14% (age 49y±16; 30%man). Absence of onsite CT imaging prohibited distinction of ischemic from hemorrhagic stroke in 196 (99%) stroke patients. Data on the time lapse between symptom onset and ER admission was available in 154/197 (78%) of stroke patients. In this group, median and mean time frame were 24-hours and 85±210-hours with 22/134 (16%) presenting in <3-hours and 11/134 (8%) presenting between 3 and 6 hours. The most common presenting symptom among patients with hypertensive encephalopathy was headache (73%); the average presenting blood pressure (BP) in this group was systolic 174±27mmHg and diastolic 108±24mmHg. The most common presenting symptoms among stroke patients included speech disturbance (47%), and altered mental status (56%). Overall in-hospital stroke mortality was 19% (38/197).

Conclusions: To our knowledge, this is the first study addressing cerebrovascular disease patterns in Haiti. Limitations on diagnostic imaging and resources contribute to high observed morbidity and mortality. Prevention, diagnosis, and treatment of cerebrovascular diseases should be prioritized in Haiti, while additional studies are necessary to better define the epidemiology of this disease.

Risk of epithelial ovarian cancer in asymptomatic women with ultrasound-detected ovarian masses: a prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS)

OBJECTIVE

To estimate the risk of primary epithelial ovarian cancer (EOC) and slow growing borderline or Type I and aggressive Type II EOC in postmenopausal women with adnexal abnormalities on ultrasound.

METHODS

This was a prospective cohort study in the ultrasound group of the UK Collaborative Trial of Ovarian Cancer Screening of postmenopausal women with ultrasound-detected abnormal adnexal (unilocular, multilocular, unilocular solid and multilocular solid, solid) morphology on their first scan. Women were followed up through the national cancer registries and by postal questionnaires. Absolute risks of EOC and borderline, Type I and Type II EOC within 3 years of initial scan were calculated.

RESULTS

Of 48 053 women who underwent ultrasound examination and had complete scan data, 4367 (9.1% (95% CI, 8.8-9.3%)) had abnormal adnexal morphology. Median follow-up was 7.09 (25(th) -75(th) centiles, 6.03-7.92) years. Forty-seven (32 borderline or Type I, 15 Type II) were diagnosed with EOC. The overall absolute risk of EOC associated with abnormal adnexal morphology was 1.08% (95% CI, 0.79-1.43%); for borderline and Type I it was 0.73% (95% CI, 0.5-1.03%); and for Type II it was 0.34% (95% CI, 0.33-0.79%). In the subgroup (n = 741) with solid elements (unilocular solid, multilocular solid and solid) overall absolute risk was 4.45% (95% CI, 3.08-6.20%), for borderline and Type I it was 3.1% (95% CI, 1.9-4.6%) and for Type II it was 1.3% (95% CI, 0.6-2.4%). 11 982 women had both ovaries visualized and normal annual scans throughout the 3-year follow-up period. In this group, no borderline or Type I and eight Type II cancers were diagnosed.

CONCLUSION

Asymptomatic postmenopausal women with ultrasound-detected adnexal abnormalities with solid elements have a 1 in 22 risk for EOC. Despite the higher prevalence of Type II EOC, the risk of borderline or Type I cancer in women with ultrasound abnormalities seems to be higher than does the risk of Type II cancer. This has important immediate implications for patients with incidental adnexal findings as well as for any future ultrasound-based screening.

Factors influencing uptake and timing of risk reducing salpingo-oophorectomy in women at risk of familial ovarian cancer: a competing risk time to event analysis

OBJECTIVE

To evaluate factors affecting uptake of risk-reducing salpingo-oophorectomy (RRSO) over time in women at high-risk of familial ovarian cancer.

DESIGN

Prospective observational cohort.

SETTING

Tertiary high-risk familial gynaecological cancer clinic.

POPULATION/SAMPLE

New clinic attendees between March 2004 and November 2009, fulfilling the high-risk criteria for the UK Familial Ovarian Cancer Screening Study.

METHODS

Risk management options discussed included RRSO and ovarian surveillance. Outcome data were analysed from a bespoke database. The competing risk method was used to model the cumulative incidence function (CIF) of RRSO over time, and the sub-hazard ratio (SHR) was used to assess the strength of the association of variables of interest with RRSO. Gray's test was used to evaluate the difference in CIF between two groups and multivariable competing risk regression analysis was used to model the cumulative probabilities of covariates on the CIF.

RESULTS

Of 1133 eligible women, 265 (21.4%) opted for RRSO and 868 (69.9%) chose screening. Women undergoing RRSO were older (49 years, interquartile range 12.2 years) than those preferring screening (43.4 years, interquartile range 11.9 years) (P < 0.0005). The CIF for RRSO at 5 years was 0.55 (95% CI 0.45-0.64) for BRCA1/2 carriers and 0.22 (95% CI 0.19-0.26) for women of unknown mutation status (P < 0.0001); 0.42 (95% CI 0.36-0.47) for postmenopausal women (P < 0.0001); 0.29 (95% CI 0.25-0.33) for parity ≥1 (P = 0.009) and 0.47 (95% CI 0.39-0.55) for a personal history of breast cancer (P < 0.0001). Variables of significance from the regression analysis were: a BRCA1/2 mutation (SHR 2.31, 95% CI 1.7-3.14), postmenopausal status (SHR 2.16, 95% CI 1.62-2.87)) and a personal history of breast cancer (SHR 1.5, 95% CI 1.09-2.06).

CONCLUSIONS

Decision-making is a complex process and women opt for surgery many years after initial risk assessment. BRCA carriers, postmenopausal women and women who had breast cancer are significantly more likely to opt for preventative surgery.

Frequency and Outcomes of Hyperlactatemia After Neurosurgery

Objectives. The aim of this study was to evaluate the incidence and significance of elevated serum lactate and its impact on outcome in postoperative neurosurgical patients admitted to neurosurgical intensive care unit (NSICU). Design. This study’s design is a retrospective analysis in a 13-bed NSICU in a tertiary care hospital. A total of 673 patients were screened and 328 patients were included in the study. Methods. Patients were divided into neurosurgery versus nonneurosurgical admissions. Neurosurgical patients were further grouped as brain surgery, spinal surgery, or intracranial vascular surgery. Reason for admission, length of stay, serum lactate levels, and survival were analyzed. Results. The incidence of hyperlactatemia (lactate level ≥2.0 mmol/L) ranged from 67% in the brain tumor group to 33% in the nonneurosurgery group. Mean serum lactates were significantly higher in the brain tumor (3.17 ± 1.99) and spinal surgery groups (2.79 ± 1.51) than in the nonneurosurgery group (1.86 ± 1.10), P < .05, but not in the intracranial vascular surgery group (2.28 ± 1.71), P > .05. The serum lactate level was not significantly associated with survival. Conclusion. Postoperative hyperlactatemia occurs frequently in neurosurgery patients but appears benign.

Optical pumping and a nondestructive readout of a single magnetic impurity spin in an InAs/GaAs quantum dot

We report on the resonant optical pumping of the | ± 1⟩ spin states of a single Mn dopant in an InAs/GaAs quantum dot which is embedded in a charge tunable device. The experiment relies on a W scheme of transitions reached when a suitable longitudinal magnetic field is applied. The optical pumping is achieved via the resonant excitation of the central Λ system at the neutral exciton X(0) energy. For a specific gate voltage, the redshifted photoluminescence of the charged exciton X- is observed, which allows a nondestructive readout of the spin polarization. An arbitrary spin preparation in the | + 1⟩ or |-1⟩ state characterized by a polarization near or above 50% is evidenced.

Principles and practice of disaster relief: lessons from Haiti

Disaster relief is an interdisciplinary field dealing with the organizational processes that help prepare for and carry out all emergency functions necessary to prevent, prepare for, respond to, and recover from emergencies and disasters caused by all hazards, whether natural, technological, or human-made. Although it is an important function of local and national governing in the developed countries, it is often wanting in resource-poor, developing countries where, increasingly, catastrophic disasters tend to occur and have the greatest adverse consequences. The devastating January 12, 2010, Haiti earthquake is a case study of the impact of an extreme cataclysm in one of the poorest and most unprepared settings imaginable. As such, it offers useful lessons that are applicable elsewhere in the developing world. Emergency preparedness includes 4 phases: mitigation or prevention, preparedness, response, and recovery. Periods of normalcy are the best times to develop disaster preparedness plans. In resource-poor countries, where dealing with the expenses of daily living is already a burden, such planning is often neglected; and, when disasters strike, it is often with great delay that the assistance from international community can be deployed. In this increasingly interconnected world, the Haiti earthquake and the important international response to it make a strong case for a more proactive intervention of the international community in all phases of emergency management in developing countries, including in mitigation and preparedness, and not just in response and recovery. Predisaster planning can maximize the results of the international assistance and decrease the human and material tolls of inevitable disasters. There should be a minimum standard of preparedness that every country has to maintain and the international assistance to achieve that. International academic medical centers interested in global health could strengthen their programs by prospectively including in them contingency planning for international relief operations. Healthcare professionals of these institutions who travel to disaster zones should rigorously prepare themselves and make provisions for collecting and reporting data, which will enrich the knowledge of this growing activity.

Adult parenteral nutrition utilization at a tertiary care hospital

BACKGROUND

Guidelines from the American Society for Parenteral and Enteral Nutrition promote appropriate use of parenteral nutrition (PN). In addition, involvement of multidisciplinary nutrition support teams (NSTs) has led to a reduction of inappropriate PN administration. This study evaluated the effect of introducing hospital-wide PN guidelines and a PN review committee on PN prescription behavior of NSTs in the authors' hospital.

METHODS

A PN guidelines form with established indications was developed and made available to the NSTs. A PN review committee was formed to assess the appropriateness of PN prescriptions and educate the NSTs if an inappropriate PN prescription was noted. The initial-phase PN prescriptions were compared with those in a later (established) phase.

RESULTS

Of a total of 614 PN prescriptions, 8.1% did not meet the established indications. The initial phase recorded 312 PN prescriptions, and the established phase had 302 prescriptions. The number of inappropriate PN prescriptions decreased significantly from 11.9% in the initial phase to 4.3% in the established phase (P = .001).

CONCLUSION

The incidence of inappropriate PN prescription was low when NSTs were closely involved in patient care. Availability of written guidelines and continuous oversight of NSTs promoted appropriate PN usage.

A multidisciplinary audit of clinical coding accuracy in otolaryngology: financial, managerial and clinical governance considerations under payment-by-results

OBJECTIVES

To audit the accuracy of otolaryngology clinical coding and identify ways of improving it.

DESIGN

Prospective multidisciplinary audit, using the 'national standard clinical coding audit' methodology supplemented by 'double-reading and arbitration'.

SETTINGS

Teaching-hospital otolaryngology and clinical coding departments.

PARTICIPANTS

Otolaryngology inpatient and day-surgery cases.

MAIN OUTCOME MEASURES

Concordance between initial coding performed by a coder (first cycle) and final coding by a clinician-coder multidisciplinary team (MDT; second cycle) for primary and secondary diagnoses and procedures, and Health Resource Groupings (HRG) assignment.

RESULTS

1250 randomly-selected cases were studied. Coding errors occurred in 24.1% of cases (301/1250). The clinician-coder MDT reassigned 48 primary diagnoses and 186 primary procedures and identified a further 209 initially-missed secondary diagnoses and procedures. In 203 cases, patient's initial HRG changed. Incorrect coding caused an average revenue loss of 174.90 pounds per patient (14.7%) of which 60% of the total income variance was due to miscoding of a eight highly-complex head and neck cancer cases. The 'HRG drift' created the appearance of disproportionate resource utilisation when treating 'simple' cases. At our institution the total cost of maintaining a clinician-coder MDT was 4.8 times lower than the income regained through the double-reading process.

CONCLUSIONS

This large audit of otolaryngology practice identifies a large degree of error in coding on discharge. This leads to significant loss of departmental revenue, and given that the same data is used for benchmarking and for making decisions about resource allocation, it distorts the picture of clinical practice. These can be rectified through implementing a cost-effective clinician-coder double-reading multidisciplinary team as part of a data-assurance clinical governance framework which we recommend should be established in hospitals.

In vitro three-dimensional modelling of human ovarian surface epithelial cells

OBJECTIVES

Ninety percent of malignant ovarian cancers are epithelial and thought to arise from the ovarian surface epithelium (OSE). We hypothesized that biological characteristics of primary OSE cells would more closely resemble OSE in vivo if established as three-dimensional (3D) cultures.

MATERIALS AND METHODS

OSE cells were cultured as multicellular spheroids (MCS) (i) in a rotary cell culture system (RCCS) and (ii) on polyHEMA-coated plastics. The MCSs were examined by electron microscopy and compared to OSE from primary tissues and cells grown in 2D. Annexin V FACS analysis was used to evaluate apoptosis and expression of extracellular matrix (ECM) proteins was analysed by immunohistochemical staining.

RESULTS

On polyHEMA-coated plates, OSE spheroids had defined internal architecture. RCCS MCSs had disorganized structure and higher proportion of apoptotic cells than polyHEMA MCSs and the same cells grown in 2D culture. In 2D, widespread expression of AE1/AE3, laminin and vimentin were undetectable by immunohistochemistry, whereas strong expression of these proteins was observed in the same cells grown in 3D culture and in OSE on primary tissues.

CONCLUSIONS

Physiological and biological features of OSE cells grown in 3D culture more closely resemble characteristics of OSE cells in vivo than when grown by classical 2D approaches. It is likely that establishing in vitro 3D OSE models will lead to greater understanding of the mechanisms of neoplastic transformation in epithelial ovarian cancers.

The "cotton bud technique" as a cure for hiccups

Persistent hiccups cause psychological and physical distress and can lead to pathology such as carotid artery dissection. Therapy of hiccups is based on small case series, often using pharmacological agents. We present a method that avoids medications or invasive interventions.

Three-dimensional in vitro cell biology models of ovarian and endometrial cancer

OBJECTIVES

This study aims to establish three-dimensional (3D) cell culture models of human ovarian and endometrial cancers and to compare biological and morphological characteristics of these models with those of two-dimensional (2D) models of the same cell lines and the primary tumours.

METHODS

3D models of ovarian and endometrial cancer cell cultures were established using a Rotary Cell Culture System. Immunohistochemical profiling and differential proteomics were used to characterize biological characteristics of multicellular spheroids (MCS) formed from these cultures. These were compared to characteristics of the same cells established in 2D and of the primary tumours from which the cell lines were derived.

RESULTS

MCSs from 3D cell cultures appeared histologically similar to the primary tumours. Immunohistochemical profiling of multiple markers, including CA125, BCL2 and p53, showed that patterns of protein expression in MCSs resemble those of the primary tumours. Proteomic profiling identified several differentially expressed protein markers between 2D and 3D cultures. These included prohibitin, which was down-regulated in 3D cultures suggesting cells proliferate less compared to 2D cultures; and VDAC1 and annexin 4, which were up-regulated in 3D cultures suggesting greater levels of apoptosis in 3D compared to 2D models.

CONCLUSION

Establishing 3D models of cancer cell lines is likely to be of value for studying the molecular and biological mechanisms of ovarian/endometrial tumour progression and for testing novel molecular targets for cancer therapy.

Sinus bradycardia associated with daclizumab in liver transplant recipients: report of 3 cases

Daclizumab is a commonly used immunosuppressive agent for prophylaxis of solid organ rejection. Although rare, the cardiovascular adverse effects of daclizumab include sinus tachycardia, hypotension, and hypertension. Here, we report 3 patients who developed significant and prolonged sinus bradycardia after receiving daclizumab following orthotopic liver transplant. Daclizumab should be considered a possible cause of bradycardia following its administration in orthotopic liver transplant.

Adrenergic and serotonergic receptor responsiveness in depression

Preliminary results are presented from a series of studies designed to characterize the regulation of release/metabolism and receptor responsiveness in the noradrenergic and serotonergic systems in acutely depressed patients and depressed patients in remission. Abnormal regulation of noradrenaline release/metabolism might be expected to be associated with the acute state of depression, while abnormalities of adrenoceptor responsiveness were hypothesized to persist in remission. Growth hormone responses to clonidine were measured as indices partially reflecting alpha 2-adrenoceptor responsiveness. Blunted responses to clonidine were found in both acutely depressed patients and patients in remission. The possible implications of these findings for the pathophysiology of the noradrenergic system in depression are discussed. Prolactin responses to the serotonergic agonist and serotonin-releasing agent fenfluramine were evaluated in acutely depressed patients, patients in remission and controls. A subset of the depressed patients appeared to have blunted prolactin responses to fenfluramine. However, very preliminary results do not show any difference in this response between patients who were acutely ill and those in remission, although the variability in both groups was great. These and related findings are discussed in terms of a possible contributory role of the serotonergic system in depression.

The modified 'Parent's Kiss' for the removal of paediatric nasal foreign bodies

Paediatric nasal foreign bodies is a common clinical problem effecting children mainly 2-8 years of age. Often treated in A & E Departments, with little or no specialised ENT experience or equipment. We present a simple, parent administered technique for removal of paediatric nasal foreign bodies. The technique is safe and effective and is easy to perform on nervous and frightened children.

Effect of lower limb compression devices on thermodilution cardiac output measurement

OBJECTIVE

The aim of this study was to determine whether lower limb (calf) sequential compression devices (SCDs) have a significant effect on thermodilution cardiac output measurements using a pulmonary artery catheter.

DESIGN

Prospective clinical investigation.

SETTING

Surgical and neurosurgical intensive care units in a university hospital.

PATIENTS

A total of 43 patients with pulmonary artery catheters and bilateral lower limb SCDs.

MEASUREMENTS AND MAIN RESULTS

Cardiac output was measured (average of three) when the SCDs were off (T1), during the first 2-4 secs of the inflation cycle (T2), during seconds 4-8 of the inflation cycle (T3), and when the SCDs were off again (T4). Cardiac output measurements were consistently lower when measured during the SCD inflation cycle. The decrease in cardiac output ranged from 7.58% to 49.5%, with a mean reduction of 24.51% in the first 2-4 seconds and 20.61% during seconds 4-8 (p < .001). Two patients displayed an increase in cardiac output during the inflation cycle; one patient had an increase of 2.78% and the other an increase of 13.5%. In 11 patients, measurements were also made using a pulse contour-analysis cardiac output device, but no changes in pulse contour-analysis cardiac output were observed during the same time period.

CONCLUSIONS

Thermodilution cardiac output measurements via a pulmonary artery catheter should not be done during the inflation cycle of lower limb SCDs because they produce a falsely low cardiac output.

Mathematical model of manganese ion catalyzed microwave deactivation of Enterococcus faecalis, Staphylococcus aureus and Escherichia coli

Enterococcus faecalis, Staphylococcus aureus and Escherichia coli survival was investigated using microwave irradiation (power 130 W) both in a water control and in the presence of a 1 microM manganese ion solution. Measured survival dependencies had "bell" shape form with maximum bacterial viability between 1-2 min of microwave heating. Additional heating revealed bacteria survival decreasing up to 3 min of microwave heating when viability became insignificantly small. The total deactivation time of bacteria in the presence of manganese ions was significantly smaller then that of bacteria irradiated in the microwave without manganese ions present (4-5 min). One possible explanation for the rapid reduction of bacterial survival during microwave irradiation in the presence of manganese ions is that increasing manganese ion penetration into bacteria along with microwave irradiation related to an increase of kinetic energy of ions, and damaging of bacteria by metal ions. The proposed mathematical model for microwave heating took into account "growth" and "death" factors of bacteria. It assumes that rates of bacterial growth and decay are linear functions of water temperature, and rate of bacterial decay that relates with metal concentration into water is also linear, which influenced the differential equation for the dependence between number of survival bacteria and temperature water. By using proportionality between the time of microwave heating and water temperature we derived the differential equation, between bacterial viability and time of microwave irradiation which was used as mathematical model for microwave heating in the presence of metal ions. This model had forms of second-degree polynomial functions. We received good relationships (with coefficient of correlation 0.92-0.99) between proposed mathematical model and experimental data for all bacterial deactivation.

Mathematical models for conventional and microwave thermal deactivation of Enterococcus faecalis, Staphylococcus aureus and Escherichia coli

Temperature dependencies of survival fecal coliforms such as Enterococcus faecalis, Staphylococcus aureus and Escherichia coli in water were investigated between 25-65 degrees C. Measured dependencies had "bell" shaped form with maximum bacterial viability at 35-45 degrees C. The rates of growth and decay of bacterial viability depend on specific forms of bacteria. At temperatures of 60-65 degrees C the number of viable bacteria decreased in one hundred times in comparison with the maximum value. Similar "bell" shape forms were found for dependencies between bacterial viability and time of microwave (dielectric) heating of water. The dependencies had maximum value at 1-2 min of microwave heating. Then, the number of viable bacteria decreased, and at 4-5 min of microwave heating, became insignificantly small. The proposed mathematical models for conventional and microwave heating took into account "growth" and "death" factors of bacteria, and had forms of second degree polynomial functions. The results showed good relationships (with coefficient correlation 0.84-0.99) between the proposed mathematical models and experimental data for both conventional and microwave heating.

Treatment of primary mucosal head and neck squamous cell carcinoma using photodynamic therapy: results after 25 treated cases

The use of photodynamic therapy for the treatment of malignant and non-malignant conditions is increasing. This paper demonstrates the efficacy of a second-generation photosensitizer, Foscan®, in the primary treatment of a wide range of mucosal head and neck squamous cell carcinomas. Tumours ranged in stage from T1 to T3. A complete response to primary treatment was seen in 19/21 patients (90 per cent). In laryngeal cancer recurrent after radical radiotherapy, one out of four patients treated obtained a complete response (25 per cent). Six patients (24 per cent) required surgery after photodynamic therapy, for local recurrence or dysplasia. Mean follow up was for 27.3 months (standard deviation 20.6 months).

‘Surgical skills box’: a new training aid for surgical trainees

Introduction: Surgical trainees now receive less operating experience with the reduction in junior doctor hours.

Design: We designed a simple, portable, versatile ‘surgical skills box’ which allowed surgical trainees to practise vascular anastomosis, suturing, tonsil ties, hand ties and grommet insertion.

Discussion: With surgical trainees now receiving reduced operating experience it is more important than ever for them to practise their surgical skills outside the operating theatre environment.

Primary mucinous carcinoid tumour of the ovary: a case report

Primary ovarian carcinoid tumours of the ovary are rare and represent less than 0.1% of ovarian malignancy. The evidence to guide treatment and prognosis of these tumours is limited. We report a case of primary ovarian mucinous carcinoid tumour, of the atypical category, in a 34-year-old nulliparous woman. Only three such cases have previously been reported. At four years from presentation, she has no signs of metastatic disease, despite delayed primary surgery and then initial conservative management. At present surgical excision with close follow-up appears to be the management of choice. This case adds to the body of evidence and demonstrates a possible good prognosis with non-aggressive behaviour in the atypical mucinous carcinoid group.

The association between polycystic ovaries and endometrial cancer

BACKGROUND

Women with polycystic ovary syndrome (PCOS) are assumed to be at increased risk of endometrial cancer (EC), albeit of a more differentiated type with better prognosis than in normal women. This study was designed to test these assumptions, as evidence for them is lacking.

METHODS

The prevalence of polycystic ovaries (PCO), as a marker of PCOS, was investigated in ovarian sections from 128 women with EC and 83 with benign gynaecological conditions. The expression of the prognostic markers p53, Ki67, Bcl2 and cyclin D1 was also investigated by immunohistochemistry in endometrial tumours from 11 women with PCO and 16 with normal ovaries.

RESULTS

Overall, PCO were similarly prevalent in women with EC (8.6%) and benign controls (8.4%); however, in women aged <50 years, PCO were more prevalent in women with EC (62.5 versus 27.3%, P = 0.033). Cyclin D1-expressing endometrial tumours tended to be more prevalent in women with PCO compared to normal ovaries (36.4 versus 6.25%, respectively, P = 0.071). Bcl2-, p53- and Ki67-expressing tumours were similarly prevalent.

CONCLUSIONS

The association between PCOS and EC appears confined to premenopausal women. The tendency for cyclin D1-expressing endometrial tumours to be more prevalent in women with PCO challenges the assumption that EC prognosis is improved in women with PCOS.

Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients

OBJECTIVE

This study was designed to assess the clinical applicability of a small, handheld, portable transthoracic echocardiography device by noncardiologist intensivists.

DESIGN

Prospective, observational study. After 10 one-hour tutorials, intensivists performed a limited transthoracic echocardiography (TTE) (2-4 views, without Doppler or M-mode) examination with the 5.6-lb SonoHeart Echo System (SonoSite, Bethell, WA) on critically ill patients admitted to the surgical intensive care unit. After initial cardiac clinical assessment in 90 patients, a limited TTE was performed by an intensivist to assess left ventricular (LV) function and LV volume status. Each study was immediately reviewed and repeated by an echocardiographer to determine the technical quality of the TTE and the accuracy of the intensivist's interpretation. Data were analyzed and presented in proportions using descriptive statistics.

SETTING

Surgical intensive care unit of an academic medical center.

PARTICIPANTS

Ninety critically ill adult patients.

INTERVENTIONS

After initial cardiac clinical assessment, a limited TTE was performed by an intensivist to assess LV size and function, to rule out significant pericardial effusions, and to estimate circulatory volume.

RESULTS

Intensivists successfully performed a diagnostic limited TTE in 94% of patients and interpreted their studies correctly in 84%. Limited TTE provided new cardiac information and changed management in 37% of patients. TTE added useful information in an additional 47% of patients but did not alter immediate management. The mean "goal-directed TTE" acquisition time was 10.5 +/- 4.2 minutes.

CONCLUSION

After a brief formal training in using this handheld echocardiographic system in intensive care unit patients, surgical intensivists successfully performed and correctly interpreted a limited TTE in critically ill patients. Limited TTE provided new information and altered management in a significant number of patients. This study supports incorporating bedside goal-directed, limited TTE into intensivists' training programs.

'Moffett's' solution: a review of the evidence and scientific basis for the topical preparation of the nose

General anaesthesia, often causes a widespread vasodilation, producing a hyperaemic nasal mucosa, hence the need for a topical application to decongest the nose and reduce the nasal blood flow to optimize the operative field. The use of a combination of cocaine, sodium bicarbonate and adrenaline given the eponymous title of 'Moffett's Solution' is standard practice in many rhinological procedures to provide local anaesthesia, vasoconstriction and decongestion. We discuss each component of 'Moffett's' reviewing the science and evidence behind its usage and the huge variation in the techniques of its application.

TP53 mutations in vulval lichen sclerosus adjacent to squamous cell carcinoma of the vulva

Non-neoplastic epithelial lesions of the vulva (NNEDV) lichen sclerosus (LS) and squamous hyperplasia (SH) have been implicated in the pathogenesis of squamous cell carcinoma of the vulva (SCC). To date, there have been no recognisable precursor lesions for SCC associated with NNEDV. TP53 is the most frequent genetic change in human cancers and can indicate both aetiology and molecular pathogenesis of tumours. A total of 27 SCC patients underwent immunohistochemistry (IHC) and TP53 mutational analysis using microdissection and direct sequencing. There were 19 patients with areas of adjacent epidermis: 17 had NNEDV (four SCCs had more than one adjacent lesion) and two had normal epidermis. In all, 70.4% of the SCCs, 40% LS and 22.2% SH demonstrated overexpression of p53. In total, 77.8% of SCCs, 46.7% of LS and 22.2% SH demonstrated mutations in TP53, with the majority of lesions having a mutation in codon 136. Eight cases were identified where the same mutation was identified in the SCC and in the adjacent area. These data suggest that TP53 mutations develop in NNEDV and are intrinsic to the clonal evolution that leads to SCC. The type of mutation detected is more likely to occur due to endogenous cellular changes rather than exogenous carcinogen exposure.

Bronchiolitis obliterans organizing pneumonia after orthotopic liver transplantation

Bronchiolitis obliterans organizing pneumonia (BOOP) has been described after bone marrow, lung, heart-lung, and renal transplantation, but rarely after orthotopic liver transplantation (OLT). We report a case of BOOP after OLT to emphasize BOOP as an under diagnosed and treatable cause of nonresolving pneumonia, which may not be preventable by maintenance low-dose prednisone. A 48-year-old man was hospitalized for dyspnea and cough one month after OLT. Among his medications were tacrolimus and prednisone. Physical examination was significant for lung crepitations and bilateral leg edema. Chest x-ray revealed bilateral infiltrates. Computed tomography (CT) of the chest demonstrated bilateral diffuse infiltrates with areas of sparing and nodularities. Bronchoscopy was normal and bronchoalveolar lavage was negative. Lung biopsy was performed and demonstrated serpiginous plugs of fibroblastic tissue filling the alveolar spaces, focal fibrosis of some alveolar septa, and reactive pneumocytic hyperplasia consistent with BOOP. Methylprednisolone was continued with clinical improvement and weaning from the ventilator, but subsequent sepsis and multisystem organ failure finally led to the patient's death.

A rare case of Crohn's disease in head and neck surgery

Oral manifestations of Crohn's disease may present to the Otolaryngologist in the form of ulceration, glossitis and odynophagia, but rarer examples of presentation are also recognized. In this case a 24-year-old lady presented with cervical lymphadenopathy, the subsequent investigation of which resulted in the identification of the disease both in this node and in the tonsils. It is noted that these lesions may precede the classical intestinal manifestations and so the Otolaryngologist could aid in the initial diagnosis of the disease. The pathogenic possibilities of how Crohn's disease might have arisen in these and other extra-intestinal regions, are discussed.