OUP accepted manuscript

Background

Combination antibiotic therapy with an antitoxin agent, such as clindamycin, is included in some guidelines for severe, toxin-mediated Staphylococcus aureus infections. The evidence to support this practice is currently limited to in vitro, animal and observational human case-series data, with no previous randomized controlled trials (RCTs).

Objectives

This pilot RCT aimed to determine the feasibility of conducting a clinical trial to examine if adjunctive clindamycin with standard therapy has greater efficacy than standard therapy alone for S. aureus infections.

Methods

We performed an investigator-initiated, open-label, multicentre, pilot RCT (ACTRN12617001416381p) in adults and children with severe S. aureus infections, randomized to standard antibiotic therapy with or without clindamycin for 7 days.

Results

Over 28 months, across nine sites, 127 individuals were screened and 34 randomized, including 11 children (32%). The primary outcome—number of days alive and free of systemic inflammatory response syndrome ≤14 days—was similar between groups: clindamycin (3 days [IQR 1–6]) versus standard therapy (4 days [IQR 0–8]). The 90 day mortality was 0% (0/17) in the clindamycin group versus 24% (4/17) in the standard therapy group. Secondary outcomes—microbiological relapse, treatment failure or diarrhoea—were similar between groups.

Conclusions

As the first clinical trial assessing adjunctive clindamycin for S. aureus infections, this study indicates feasibility and that adults and children can be incorporated into one trial using harmonized endpoints, and there were no safety concerns. The CASSETTE trial will inform the definitive S. aureus Network Adaptive Platform (SNAP) trial, which includes an adjunctive clindamycin domain and participants with non-severe disease.

Selective Looking and the Müller-Lyer Illusion: The Effect of Changes in the Focus of Attention on the Müller-Lyer Illusion

According to a selective looking paradigm subjects were required to attend to the inward-going or outward-going components of a combined Müller-Lyer figure in which both components were present and distinguishable by colour. The amount of the illusion was found to vary according to which component the subject attended. Subsidiary findings relate the amount of the illusion to fin angle, fin length, and length of shaft.

Mucormycosis in Australia: contemporary epidemiology and outcomes

Mucormycosis is the second most common cause of invasive mould infection and causes disease in diverse hosts, including those who are immuno-competent. We conducted a multicentre retrospective study of proven and probable cases of mucormycosis diagnosed between 2004-2012 to determine the epidemiology and outcome determinants in Australia. Seventy-four cases were identified (63 proven, 11 probable). The majority (54.1%) were caused by Rhizopus spp. Patients who sustained trauma were more likely to have non-Rhizopus infections relative to patients without trauma (OR 9.0, p 0.001, 95% CI 2.1-42.8). Haematological malignancy (48.6%), chemotherapy (42.9%), corticosteroids (52.7%), diabetes mellitus (27%) and trauma (22.9%) were the most common co-morbidities or risk factors. Rheumatological/autoimmune disorders occurred in nine (12.1%) instances. Eight (10.8%) cases had no underlying co-morbidity and were more likely to have associated trauma (7/8; 87.5% versus 10/66; 15.2%; p <0.001). Disseminated infection was common (39.2%). Apophysomyces spp. and Saksenaea spp. caused infection in immuno-competent hosts, most frequently associated with trauma and affected sites other than lung and sinuses. The 180-day mortality was 56.7%. The strongest predictors of mortality were rheumatological/autoimmune disorder (OR = 24.0, p 0.038 95% CI 1.2-481.4), haematological malignancy (OR = 7.7, p 0.001, 95% CI 2.3-25.2) and admission to intensive care unit (OR = 4.2, p 0.02, 95% CI 1.3-13.8). Most deaths occurred within one month. Thereafter we observed divergence in survival between the haematological and non-haematological populations (p 0.006). The mortality of mucormycosis remains particularly high in the immuno-compromised host. Underlying rheumatological/autoimmune disorders are a previously under-appreciated risk for infection and poor outcome.

Are physicians prepared for whole genome sequencing? a qualitative analysis

Although the integration of whole genome sequencing (WGS) into standard medical practice is rapidly becoming feasible, physicians may be unprepared to use it. Primary care physicians (PCPs) and cardiologists enrolled in a randomized clinical trial of WGS received genomics education before completing semi-structured interviews. Themes about preparedness were identified in transcripts through team-based consensus-coding. Data from 11 PCPs and 9 cardiologists suggested that physicians enrolled in the trial primarily to prepare themselves for widespread use of WGS in the future. PCPs were concerned about their general genomic knowledge, while cardiologists were concerned about how to interpret specific types of results and secondary findings. Both cohorts anticipated preparing extensively before disclosing results to patients by using educational resources with which they were already familiar, and both cohorts anticipated making referrals to genetics specialists as needed. A lack of laboratory guidance, time pressures, and a lack of standards contributed to feeling unprepared. Physicians had specialty-specific concerns about their preparedness to use WGS. Findings identify specific policy changes that could help physicians feel more prepared, and highlight how providers of all types will need to become familiar with interpreting WGS results.

Knowing prior methicillin-resistant Staphylococcus aureus (MRSA) infection or colonization status increases the empirical use of glycopeptides in MRSA bacteraemia and may decrease mortality

To compare the management and outcome of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in patients known to be MRSA-colonized/infected (C-patients) with the management and outcome in those not known to be colonized/infected (NC-patients), we conducted a 10-year retrospective review of MRSA bacteraemia in an adult tertiary hospital. Clinical data were obtained by chart review, and mortality data from linked databases. Prior MRSA colonization/infection status was available to treating clinicians at the time of the bacteraemia as a 'Micro-Alert' tag on the patient's labels, in medical charts, and in electronic information systems. C-patients accounted for 35.4% of all MRSA bacteraemia episodes. C-patients were more likely to be indigenous, to be diabetic, or to have a history of previous S. aureus infection. Markers of illness severity (Simplified Acute Physiology Score (SAPS)-II, need for admission to the intensive-care unit, length of stay, and metastatic seeding) were similar in both groups. Empirical therapy included a glycopeptide in 49.3% of C-patients vs. 18.9% of NC-patients (p <0.01), and contained an antibiotic to which the MRSA isolate tested susceptible in vitro in 56.7% of C-patients vs. 45.1% of NC-patients (p 0.13). All-cause 7-day and 30-day mortality were 7.5% vs. 18.9% (p 0.04), and 22.4% vs. 31.1% (p 0.20), in the C-patient and NC-patient groups, respectively. Knowing MRSA colonization status was significantly associated with lower 30-day mortality in Cox regression analysis (p <0.01). These data suggest that mortality from MRSA bacteraemia is lower in C-patients, which may reflect the earlier use of glycopeptides. The low use of empirical glycopeptides in septic patients known to be previously MRSA-colonized/infected may represent a missed opportunity for infection control to positively impact on clinical management.

Prevalence of nasal methicillin-resistant Staphylococcus aureus colonization in healthcare workers in a Western Australian acute care hospital

Due to a longstanding comprehensive "search and destroy policy", methicillin-resistant Staphylococcus aureus (MRSA) is not endemic in Western Australian (WA) acute care hospitals. As the prevalence of MRSA in the community has increased, healthcare workers (HCW) are at risk of importing MRSA into hospitals. We aimed to determine the prevalence of and risk factors for nasal MRSA colonization in our HCW population. A period prevalence study was conducted at an 850-bed tertiary hospital. Basic demographics and a nasal swab were obtained. A total of 1,542 HCWs employed in our centre were screened for MRSA, of whom 3.4% (n = 52) were colonized. MRSA colonization was more common in patient care assistants (6.8%) and nurses (5.2%) than in allied health professionals (1.7%) and doctors (0.7%) (p < 0.01). Working in "high-risk" wards that cared for MRSA colonized/infected patients was the strongest risk factor for HCW MRSA colonization (p < 0.001). ST1-IV and ST78-IV (the most common community clones in the region) were the most frequently identified clones. In conclusion, MRSA colonization of HCWs occurs primarily in HCWs caring for patients colonized or infected with MRSA. Surveillance screening of HCWs should be regularly performed on wards with patients with high MRSA colonization prevalence to prevent further spread in the hospital.

Clinical and laboratory features of invasive community-onset methicillin-resistant Staphylococcus aureus infection: a prospective case-control study

Differences between the features of invasive community-onset methicillin-resistant Staphylococcus aureus (cMRSA) and methicillin-susceptible S. aureus (cMSSA) infections are incompletely understood. Fifty-seven patients with invasive cMRSA infection were prospectively identified at two teaching hospitals; for each cMRSA case, two cases of invasive cMSSA infection acted as controls. The primary outcome was 30-day all-cause mortality. Patients with invasive cMRSA infection were more likely to be Aboriginal (25% vs. 14%, age-adjusted odds ratio [OR] 2.5, p = 0.037), reside in a long-term care facility and/or have been hospitalised in the previous year (51% vs. 34%, p = 0.04) and less likely to have endocarditis (2% vs. 12%, p = 0.02) or require admission to an intensive care unit or high-dependency area (7% vs. 21%, p = 0.02). All-cause mortality at 30 days was similar in the cMRSA and cMSSA groups (9% vs. 7%, p = 0.68). Panton-Valentine leukocidin (PVL) genes were detected in a similar proportion of cMRSA and cMSSA isolates (32% vs. 27%, p = 0.49) and the presence of PVL genes was associated with younger age (35 years vs. 55 years, p < 0.001), Aboriginal ethnicity (38% vs. 10%, p < 0.001), skin and soft-tissue infection (54% vs. 19%, p < 0.001), lower illness severity at presentation (SAPS II score 9 vs. 21, p = 0.001) and shorter hospitalisation (9 days vs. 24 days, p < 0.001). Patients with "PVL-positive" and "PVL-negative" S. aureus infection had similar 30-day all-cause mortality (4% vs. 9%, p = 0.28). Few clinical features differentiated patients with invasive cMRSA infection from those with infection caused by cMSSA. Invasive "PVL-positive" S. aureus infection was associated with less morbidity but similar mortality to "PVL-negative" infection.

Risk factors and outcomes of methicillin-resistant Staphylococcus aureus bacteraemia in critically ill patients: a case control study

Methicillin-resistant Staphylococcus aureus (MRSA) infection is an increasing threat to critically ill patients in many intensive care units. MRSA bacteraemia is an extreme form of MRSA infection and is a significant cause of morbidity and mortality. This case control study aimed to assess the risk factors and outcomes of MRSA bacteraemia compared to methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia. A total of 21 MRSA bacteraemia and 60 randomly selected MSSA bacteraemia episodes, admitted to the intensive care unit at Royal Perth Hospital between 1997 and 2007, were considered. There was a suggestion that hospitalisation within the preceding six months (P = 0.087) and residence in a long-term care facility (P = 0.065) were associated with a higher risk of MRSA bacteraemia. MRSA bacteraemia was more often treated with antibiotics to which the pathogen was not susceptible in vitro (38.1% vs 0%, P = 0.001), resulting in a longer duration of fever (median 7.0 vs 2.0 days, P= 0.009) and bacteraemia (mean 3.2 vs 0.6 days, P = 0.005) and a higher incidence of metastatic seeding of infection (52.4% vs 21.7%, P = 0.012) as compared to MSSA bacteraemia. While in-hospital mortality between MRSA and MSSA was similarly high (47.6% vs 38.3% for MRSA and MSSA respectively, P = 0.607), a significant proportion of the patients who had MRSA bacteraemia died within five years of hospital discharge (36.4%, hazard ratio 26.0, 95% confidence interval 1.90 to 356.7, P = 0.015). Infections contributed to 75% of the deaths after hospital discharge in patients who had an episode of MRSA bacteraemia. MRSA bacteraemia carries a much worse long-term prognosis than MSSA bacteraemia and that could be explained by recurrent MRSA infections and residual confounding.

[Utility of procalcitonin for the diagnosis and the follow-up of infections in febrile neutropenic patients]

Procalcitonin is a marker of severe bacterial infections in non-neutropenic patients. The goal of this review is to assess its utility in the management of neutropenic patients. A delayed treatment of infection in this setting results in severe morbidity and high mortality. As traditional diagnostic tools often fail to exclude infection when fever occurs, all these patients receive empirical antimicrobial therapies during long periods of time. Present knowledge suggests that procalcitonin may contribute to identify patients in whom 1) antibiotics could be stopped in the absence of bacterial infection, 2) investigations and adjustments of the antimicrobial therapy for persistent fever are needed. The use of procalcitonin for the management of febrile neutropenic patients should be studied prospectively.

Form and movement in stereokinetic cycloids: motion lost and found

In exploring stereokinesis, we devised flat cycloidal display figures which, when rotated on a disc in the frontal plane, are perceived as illusory three-dimensional forms with movement in depth; the dominant percepts were of twisted loops with an internal writhing motion. These dominant forms could be convincingly represented by stereo pairs derived from the flat display; related forms, not seen in the illusion, could also be constructed, seeming to show a selectivity for preferred stereokinetic forms by the perceptual system. Models were made of the stereo forms; when rotated, they showed similar illusions and selectivity. We suggest that the illusions arise because some components of the real motion do not appear in the sensory field. The perceptual system accommodates for this by constructing percepts which are not necessarily veridical but do reconcile form and motion into a coherent unity. The results are discussed in relation to concepts of invariance and rigidity, and with regard to the creative response to sensory data by the perceptual system.

Elements for a report card: one institution's experience moving from theory to trial

The emerging computerized patient record, the movement toward a unified nursing language, and increasing accountability to the public for clinical outcomes are converging forces that require a coherent plan if nursing is to evaluate outcomes. The article describes a nursing service and school of nursing's approach and beginning experiences in identifying concepts and indicators that are useful to clinicians. These concepts and indicators have the potential to be embedded in a concurrent information system that would feed a data repository used retrospectively by clinicians and researchers. The article also discusses results to date and lessons learned.

Stereokinetic interaction effects involving static and slowly moving identical figures

Here a new depth effect evoked by the spatial and temporal interaction in 2-D of a slowly moving circle (optimally at 0.6 rads/sec) with an identical static circle is reported. Typically, respondents report that with increasing adjacency, commencing with separations of a few diameters, the moving circle appears in a different plane of depth to the static circle, it then usually appears to "dip" onto the static circle and after complete coincidence with it to rise away from it. This effect, together with a number of associated descriptions are commented upon, in addition to observations when viewing overlapped static circles and overlapped circles in motion, this latter stimulus condition evoking the stereokinetic effect. The authors have previously suggested that contour "sliding," which simulates motion parallax, is the key to understanding stereokinesis. The stimulus conditions giving rise to this new effect directly simulate the motion parallax information present in a retinal image.

The subjective effects of low-dose propofol. A double-blind study to evaluate dimensions of sedation and consciousness with low-dose propofol

In this study the subjective effects (sedation and mood) of subanaesthetic doses of propofol were examined in 28 healthy male volunteers. A computer model was used to predict the infusion profiles necessary to obtain steady state propofol plasma concentrations of 0.3 microgram.ml-1, 0.6 microgram.ml-1, 0.9 microgram.ml-1. Objective measures of sedation from saccadic eye movement and choice reaction time gave significant dose responses at each level but a battery of psychometric tests failed to show dose-related subjective responses. Of particular note in the subjective data is the lack of a difference between groups or even of a consistent trend within the data. This suggests that a low concentration of propofol in plasma does not induce euphoria or a sense of well-being. The anecdotal evidence available for mood changes with propofol therefore remains unsubstantiated.

Interaction of H2-receptor antagonists and benzodiazepine sedation. A double-blind placebo-controlled investigation of the effects of cimetidine and ranitidine on recovery after intravenous midazolam

H2-receptor antagonists differentially inhibit cytochrome P450 and this may affect the rate at which benzodiazepines are metabolised. However, it is not known whether this delayed clearance results in prolonged psychomotor impairment. In a randomised double-blind trial 28 healthy volunteers received two single doses of midazolam (0.07 mg.kg-1) at an interval of one week during which they took cimetidine 400 mg, ranitidine 150 mg or placebo, each twice daily. Recovery from the benzodiazepine was monitored on each occasion over a 12 h period using a battery of psychometric tests. There was wide individual variation in performance; however, an overall measure of impairment indicated a significant difference at 2.5 h (p < 0.05), the cimetidine group having a high impairment score. This decrement appeared to be in cognitive and psychomotor functions and was not reflected in the subjective assessment.

Propofol in short gynaecological procedures. Comparison of recovery over 2 days after anaesthesia with propofol or thiopentone as sole anaesthetic agent

Recovery was assessed over 48 hours after anaesthesia with propofol or thiopentone as sole anaesthetic agent in 36 unpremedicated gynaecological patients. Immediate recovery, as measured by the Steward scale, was shown to be quicker for the patients given propofol. At one hour postoperatively the thiopentone group showed impaired visual-motor coordination on the aiming test (p less than 0.01) and dexterity task (p less than 0.05), and a slowing of reaction time (p less than 0.01). Patients given propofol showed only an increase in reaction time (p less than 0.05). By 2 hours the thiopentone group showed impairment only in the aiming task (p less than 0.05). No further significant impairment was detected at 4, 24 or 48 hours. However, patients reported symptoms throughout the 48 hours indicative of residual drug effects. There was a substantial practice effect with some tests which may have obscured impairment. It can be argued therefore that the better recovery profile after propofol is still evident at 24 hours.

Reversal of benzodiazepine sedation with the antagonist flumazenil

The effectiveness of the benzodiazepine antagonist, flumazenil, was evaluated in a randomized double-blind clinical study in which diazepam 0.2 mg kg-1 or midazolam 0.1 mg kg-1 was used for i.v. sedation. We studied 120 day-case patients undergoing gastroscopy and treated with either flumazenil 0.1-2 mg or placebo after the procedure. Psychometric assessment of four aspects of recovery over a 3-h period showed that flumazenil attenuated the sedative effects of the benzodiazepines, but did not antagonize the sedation completely. For patients sedated with diazepam, there was a significant effect of flumazenil on speed of motor co-ordination after 90 min (P less than 0.01), and for those given midazolam a similar effect was found at 20 min (P less than 0.01). However, after 3 h all four groups of patients had not returned to baseline performance in accuracy of motor co-ordination (P less than 0.01) and cortical arousal (P less than 0.05), and the two groups sedated with diazepam still displayed memory deficits (P less than 0.05). Flumazenil did not attenuate the subjective experience of sedation as measured by visual analogue scales. These results indicate that sedation is multidimensional, differentially affecting the hierarchy of cognitive functions. In day-cases, antagonism of benzodiazepine sedation with flumazenil would not hasten the safe discharge of patients.

Longitudinal studies of virulence factors of Pseudomonas aeruginosa in cystic fibrosis

Among 111 strains of Pseudomonas aeruginosa from 49 children with cystic fibrosis, duration of colonization correlated with bacterial phenotype. We confirmed that P. aeruginosa from chronically colonized patients tended to be less motile, produce lower levels of protease and elastase, to be more sensitive to normal serum and to be polyagglutinating or untypable with standard antisera. We also showed that phospholipase and heat-stable hemolysin, concerned in metabolism of inorganic phosphate, and exotoxin A, were lower in these isolates. In longitudinal studies there was a decrease in virulence properties when isolates from the same patient were compared. No reversion from altered phenotype to 'wild-type' characteristics was found.

Life events and family history in children with recurrent abdominal pain

Children suffering from recurrent abdominal pain (RAP) were compared with matched controls on measures of illness behaviour, parents' illness behaviour, early parent-child relationships and stressful life events. Relatively, the RAP children stayed away from school more, needed more attention when ill, tended to show more anxiety in various ways, had parents who reported more symptoms, and had suffered a greater number of stressful experiences in the few months before pain onset.

Comparison of diazepam with midazolam as i.v. sedation for outpatient gastroscopy

We studied 26 patients in a double-blind investigation to compare psychomotor and cognitive recovery for 30 h after sedation for day-case gastroscopy with i.v. diazepam 0.15 mg kg-1 or midazolam 0.07 mg kg-1. Significantly more patients reported side effects at 7, 10 and 30 h post-gastroscopy after diazepam than after midazolam (P less than 0.05). Compared with baseline, the midazolam group was significantly impaired in critical flicker fusion threshold, reaction time, dexterity and visualization tasks up to 4 h after administration (P less than 0.05). There was a significant association between midazolam and amnesia for the procedure (P less than 0.001).

Propofol-induced anaesthesia. Double-blind comparison of recovery after anaesthesia induced by propofol or thiopentone

Postoperative psychomotor and cognitive recovery were assessed after anaesthesia induced by either propofol or thiopentone, and maintained with nitrous oxide and halothane in 40 unpremedicated dental patients. Performance was shown to be impaired one hour postoperatively for the whole sample in hand-eye coordination (p less than 0.001), reaction time (p less than 0.001) and digit span (p less than 0.05). There was evidence of impairment at 3 hours postoperatively in reaction time (p less than 0.05) and ataxia (p less than 0.01). Performance also deteriorated in the dexterity and aiming tasks. Patients reported significantly less clumsiness by 24 hours in blurred vision and shivering (p less than 0.05) and by 48 hours less coughing (p less than 0.05). However, there was no significant difference between groups. No evidence showed that recovery in the propofol group was faster, so it was concluded that induction with propofol offered no advantage when anaesthesia is maintained with nitrous oxide and halothane for the periods of time reported in this study.

A double-blind comparison between nitrazepam, lorazepam, lormetazepam and placebo as preoperative night sedatives

Benzodiazepines are used as hypnotics to reduce anxiety and give a good night's sleep on the night prior to surgery. In a double-blind procedure, patients were given either lorazepam (2 mg or 4 mg), lormetazepam (1 mg or 2 mg), nitrazepam 10 mg or placebo. Measures were taken of sleep, anxiety, memory and after-effects. There was no evidence that the drugs reduced anxiety, nor evidence of amnesia. Quality and length of sleep was shown to be better for nitrazepam (P less than 0.05), lorazepam 2 mg (P less than 0.05) and lorazepam 4 mg (P less than 0.01), compared with placebo. However, significantly higher ratings of clumsiness and confusion as after-effects were found with nitrazepam (P less than 0.05), and clumsiness (P less than 0.005), slurred speech and blurred vision (P less than 0.01), sleepiness, nausea, weakness and confusion (P less than 0.05) with lorazepam 4 mg. It was concluded that lorazepam 2 mg produced the greatest net benefit.

Psychological resources and cigarette smoking in adolescents

Despite society's increasing awareness of the adverse health consequences of cigarette use, adolescents continue to take up smoking. This study suggests that adolescents may smoke in order to alleviate the stress engendered by the adjustment demands of this period and that adolescents with fewer coping resources should be more likely to use cigarettes. An examination of the relationship between psychological resources and cigarette use indicated that adolescents who smoked had lower self-esteem, a more external locus of control orientation and a higher level of trait anxiety compared with adolescents who did not smoke. The findings suggest that smoking performs a stress management function for those adolescents with a low sense of personal effectiveness.

Apparent height of a stereokinetic cone is decreased by departure from circularity

Subjects made judgements of the comparative height of the stereokinetic cones seen for pairs of rotating figures with varying eccentricity and ellipticity. For any given eccentricity, ellipticity of the figure reduced the apparent height, with narrow ellipses seeming to be shallower. The effect is attributed to an interaction in constancy scaling.

The impossibly twisted Pulfrich pendulum

Two Pulfrich pendulums swinging in opposite phase present impossible twisting effects and also size-constancy effects.

Treatment of breast cancer through the ages

Considerable controversy still exists regarding the correct management of cancer of the breast. This short history follows the paths of thought and practice from the Egyptian dynasties to modern times. A description is given of the pathologic reasons for the variance in local treatment and the development of adjuvant therapy.

The frequent consulter in primary medical care

A comparison is reported between a group of frequent consulters of general medical practitioners and a group of infrequent consulters. The frequent consulters reported more symptoms, particularly upper respiratory, gastro-intestinal and back troubles. They took more proprietory medicines and more vitamin pills and were less inclined to ignore symptoms. They were more inclined to negative mood. Although they had slightly fewer stressful life events they coped less well with them, perhaps because they had less satisfactory family and social support and found less distraction in social activities. By means of a model the symptoms of these subjects are contrasted with symptoms found in psychosomatic disorder.

Shape, height and angular movement in stereokinesis

Cues affecting the apparent height (depth) of a stereokinetic 'core' were investigated by comparing heights for pairs of rotating figures. Apparent height was shown to be independent of the number of bands on the figure and of the geometric perspective by which it was drawn. On the other hand, apparent height was strongly dependent on eccentricity within the figure, with maximum apparent height being achieved at full eccentricity. The reason for the existence of such a definite maximum remains obscure.

Invasiveness of Aeromonas spp. in relation to biotype, virulence factors, and clinical features

Of 69 fecal isolates of Aeromonas spp., 18 had the ability to invade HEp-2 cells. Invasiveness correlated with biotype; of the 18 invasive strains, 16 were A. sobria and 2 were A. hydrophila. No invasive strains were found among the A. caviae. Of the 18 invasive strains, 13 were enterotoxigenic. Of the enterotoxigenic and invasive strains, 12 were A. sobria, but enterotoxicity was also more common among noninvasive strains of A. sobria. Fucose-resistant hemagglutination was also more common in A. sobria, but invasive strains were equally divided between fucose-resistant hemagglutination and other patterns. Detailed clinical information was available for 27 of the 69 strains. All 15 strains of A. sobria or A. hydrophila associated with diarrhea were enterotoxigenic; 6 of the 10 strains of A. sobria were also invasive. Blood was present in the stool samples of five of the six patients with invasive A. sobria and in none of the patients with noninvasive strains. Although limited, these observations suggest that dysenteric symptoms may be produced by invasive Aeromonas spp.

The barber-surgeons of London

The Company of the Barber-Surgeons of London was formed by the union of the Company of Barbers and the Fellowship of Surgeons in 1540. It marked one of the great milestones in English surgery. The barbers had carried out minor surgery such as bleeding and lancing of abscesses, while the more erudite surgeons attempted to evolve some principles in surgery, and were involved in the mutilating surgery of warfare. The Barber-Surgeons became responsible for instigating teaching programs and the licensing of men to practice the art of surgery; they also appointed surgeons to the armed forces. An inevitable rift between these two different types of people occurred in 1745. The surgeons broke away and formed the Company of Surgeons, which, in 1800, became the Royal College of Surgeons.

An evaluation of two antenatal information booklets

The readability of two antenatal education books which are widely distributed to expectant mothers was assessed. There were some significant differences, and it was anticipated that this would be reflected in the levels of information imparted to the mothers, particularly when they were analysed by social class. In practice the differences were small, and the only one of significance was that the book which was believed to be more readable and more attractive in format resulted in higher knowledge scores in social classes I and II, but not in social classes III to V. Possible explanations for this are discussed. Clear benefit in terms of knowledge was demonstrated when mothers received a book in advance of their attendance at the antenatal booking clinic. They arrived better prepared and better informed, with knowledge to help the healthy development of the foetus at an early stage in pregnancy. The additional postage costs in sending out booklets is considered justifiable.

Anxiety during a crisis: emotional effects of screening for neural tube defects

Anxiety was assessed in prospective mothers undergoing screening for foetal neural tube defects. Anxiety was found to be extreme and only returned to normal levels when a definitely negative amniocentesis result was communicated to the woman. Anxiety was mitigated by social and family support but other life events had little effect on it.

Wobble cones and wobble holes: the stereokinetic effect revisited

It is well-known that patterns of eccentric circles when slowly rotated give rise to compelling three-dimensional impressions of cones or conical holes which can 'wobble' as the pattern rotates. The wobble can be considered as part of the overall phenomenon of depth elicited from a rotating display, the 'stereokinetic' effect (SKE). This paper considers the three-dimensional appearance as being the result of the sliding of contours and thus it imitates the motion parallax found in real three-dimensional objects in motion. New variants of SK figures are used to examine these points. An analogy with computer programs is proposed which questions earlier views on the location of perceptual invariance.

Screening for neural-tube defects and maternal anxiety

Anxiety levels were studied in 176 women with raised serum alpha-fetoprotein levels at 16-18 weeks gestation, at the time they attended a central assessment clinic, and again 2-3 weeks later in those not found to have a fetus with a neural-tube defect. Methods of imparting information about the serum screening tests and the manner in which a normal amniotic fluid result was conveyed to the patient were also studied. Overall, women attending the clinic for further assessment were extremely anxious, irrespective of the source of their information. Anxiety scores 2-3 weeks after testing were greatly influenced by whether the patient had been given a definite normal result or whether she was told to assume that the result was normal if she did not hear from the clinic. Patients who, after reassessment, did not require amniocentesis had some residual anxiety in spite of verbal reassurance.

Binocular filters as an aid to color discrimination by dichromats

A method is described for improving color discriminations in dichromats by means of glasses with one magenta and one cyan eyepiece. A modest improvement is reported and discussed.

Maternal opinion about analgesia for labour. A controlled trial between epidural block and intramuscular pethidine combined with inhalation

In a randomised controlled trial epidural analgesia with bupivacaine 0.5% (mean dose 112.8 mg) was compared with pethidine (mean dose 200 mg) and inhalational analgesia in primipara (28 and 30 mothers) and multipara (17 and 18 mothers). Mothers who had an uneventful pregnancy and labour and agreed to have either treatment were studied during labour and followed-up at interviews for 5 months after delivery. Epidural block was rated significantly superior in respect of pain relief and comfort, there were no differences between the groups in reports of perineal discomfort. Twice as many primipara required forceps delivery after epidural block. Very few mothers, in each group, reported something missing in their experience of childbirth. Two thirds of each group would use the same method again. Epidural block can therefore be recommended to uncommitted mothers as a satisfying and effective method of pain relief for labour.

Self-administered intravenous and intramuscular pethidine. A controlled trial in labour

In a randomised controlled trial of mothers in labour intramuscular pethidine 150 mg, repeated if necessary, was compared with self-administered intravenous pethidine (0.25 mg/kg available at 10-min-intervals). Each mother agreed to have either method of pain relief and could opt for epidural block. The intramuscular group had significantly more pethidine than the intravenous group (mean differences, primipara 29 mg; multipara 16 mg). Ratings by mothers of the pain of 1st, 2nd stage and overall (analogue scores and gradings) were consistently better for the intravenous group although not significantly different. There were no differences in mean Apgar scores between the babies in the groups. In mothers who do not choose epidural block, similar pain relief is afforded by adequate intramuscular pethidine or self-demand intravenous pethidine; however, intravenous self-administration is more efficient since the pain relief is achieved with a lower dose of pethidine.

The reliability of a linear analogue for evaluating pain

A linear analogue for rating pain with 10, 15 and 20 cm lines is significantly less variable than a 5 cm line (mean error of 15 cm line is 0-19%, 95% confidence limits for the group +/- 2% and an inood correlation between repeated ratins of a recalled pain distant in time. The variance of the rating is significantly less than the repeated rating of a random mark. The linear analogue rating of a constant pain stimulus is reproducible and changes in rating are likely to be real changes of opinion. Pethidine 150 mg intramuscularly had no significant effect, tested 30 minutes after the administration, on the accuracy or reproducibility of the analogue rating. A linear analogue seems a suitable method of recording the patient's opion of a severe pain such as that of labour.

Cancer of the stomach: a review of 854 patients

A review is presented of 854 patients suffering from cancer of the stomach who attended St Bartholomew's Hospital between 1948 and 1962. The presentations and methods of investigations showed little change over the 15-year period, which is similar to other large series. The symptoms of anaemia and indigestion appear to be paramount in making an early diagnosis, and negative barium meal studies should not be accepted when these two symptoms are present. There are indications that early laporotomy and a more aggressive surgical approach may increase the 5-year survival rate.