Point of Care Ultrasound in the Diagnosis and Management of Severe Ovarian Hyperstimulation Syndrome

Presentation A 32year old woman, presented with a 5-day history of non-productive cough, chest pain, shortness of breath andabdominal bloating. She had undergone Embryo Transfer Treatment 6 days previously. Diagnosis A point of care ultrasound (POCUS) exam was performed as part of her initial investigations which showed right pleuraleffusion, ascites and cystic ovaries. Treatment She received Oxygen, IV Fluids and Antibiotics and was referred to the Obstetricians. Discussion Point of care ultrasound (POCUS) aided the prompt diagnosis of ovarian hyperstimulation syndrome (OHSS) in thispatient, making it possible for her to receive appropriate resuscitation and referral and an excellent outcome despitethis being a case of severe ovarian hyperstimulation syndrome.

Late results of surgical treatment of transposition of the great arteries

In summary, many of these patients have achieved a normal working capacity, but as a group there is a statistically significant reduction when compared to healthy children (p < 0.01). There was no significant difference between the group of patients who had their Mustard operation in infancy and later. As yet, there is no suggestion that the older patients, or those with the longest time interval between the operation and the exercise test, have a progressive reduction in working capacity. The decreased working capacity and moderate increase in ventilation suggests restricted cardiac output on exercise. This could be related to the abnormal heart rate response rather than indicating poor ventricular function. Equally, a restricted cardiac output on exercise may be due to inefficiency of atrial transport, tricuspid regurgitation or unmasked pulmonary vascular obstructive disease. Further studies may clarify these points. This study demonstrated that the exercise performance of asymptomatic patients 6-13 years after Mustard's operation was somewhat diminished, compared with a group of normal children. Nevertheless, these patients did lead and enjoy a normal life. Only longitudinal studies may bring the final answer to the important question: How many patients will be alive with normal or near normal exercise tolerance 40-50 years after Mustard's operation? Until such an answer is available, we believe that the Mustard operation should be used in the treatment of TGA, while the alternative techniques are carefully explored.

Infants with FPIES to solid food proteins--chicken, rice and oats

We present two cases of Food Protein Induced Enterocolitis Syndrome (FPIES), a non-IgE mediated food hypersensitivity. FPIES induces severe vomiting 1.5-to-3 hours post ingestion of the offending food, and may be associated with diarrhoea, hypovolemic shock and acidosis. Avoidance of that food will lead to resolution of symptoms and prevents further episodes.

Ovarian steroid hormones: effects on immune responses and Chlamydia trachomatis infections of the female genital tract

Female sex hormones are known to regulate the adaptive and innate immune functions of the female reproductive tract. This review aims to update our current knowledge of the effects of the sex hormones estradiol and progesterone in the female reproductive tract on innate immunity, antigen presentation, specific immune responses, antibody secretion, genital tract infections caused by Chlamydia trachomatis, and vaccine-induced immunity.

STEPS: lean thinking, theory of constraints and identifying bottlenecks in an emergency department

This study aimed to identify the bottlenecks in patients' journeys through an emergency department (ED). For each stage of the patient journey, the average times were compared between two groups divided according to the four hour time frame and disproportionate delays were identified using a significance test These bottlenecks were evaluated with reference to a lean thinking value-stream map and the five focusing steps of the theory of constraints. A total of 434 (72.5%) ED patients were tracked over one week. Logistic regression showed that patients who had radiological tests, blood tests or who were admitted were 4.4, 4.1 and 7.7 times more likely, respectively, to stay over four hours in the ED than those who didn't The stages that were significantly delayed were the time spent waiting for radiology (p = 0.001), waiting for the in-patient team (p = 0.004), waiting for a bed (p < 0.001) and ED doctor turnaround time (p < 0.001).

Gastrointestinal targets of appetite regulation in humans

The aim of this paper is to describe and discuss relevant aspects of the assessment of physiological functions - and related biomarkers - implicated in the regulation of appetite in humans. A short introduction provides the background and the present state of biomarker research as related to satiety and appetite. The main focus of the paper is on the gastrointestinal tract and its functions and biomarkers related to appetite for which sufficient data are available in human studies. The first section describes how gastric emptying, stomach distension and gut motility influence appetite; the second part describes how selected gastrointestinal peptides are involved in the control of satiety and appetite (ghrelin, cholecystokinin, glucagon-like peptide, peptide tyrosin-tyrosin) and can be used as potential biomarkers. For both sections, methodological aspects (adequacy, accuracy and limitation of the methods) are described. The last section focuses on new developments in techniques and methods for the assessment of physiological targets involved in appetite regulation (including brain imaging, interesting new experimental approaches, targets and markers). The conclusion estimates the relevance of selected biomarkers as representative markers of appetite regulation, in view of the current state of the art.

Effect of rituximab (R) on clinical outcomes after autologous stem cell transplantation (ASCT) in pts with relapsed or refractory diffuse large B-cell lymphoma (DLBCL)

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Background: First-line chemotherapy cures ∼50% of pts with DLBCL, while salvage therapy followed by ASCT can cure another ∼30%. R significantly improves response rates to 1st line therapy. This retrospective study was designed to test the hypotheses that: 1) ASCT is effective in pts relapsed after R-chemotherapy and 2) addition of R to salvage improves outcomes after ASCT. Methods: We identified 84 pts with relapsed/refractory DLBCL who underwent ASCT at our institution between 1990 and 2006. In all, 32% received a R-chemo 1st line regimen and 27% received R with salvage. The median age at ASCT was 49 yrs and the median time from diagnosis to ASCT was 16 mos. High-dose regimens included BCV (48%), BEAM (8%) and alkylator/TBI (20%). Results: Overall response rate (ORR) after ASCT was 52%, with 37% of pts in CR by day 100. Among those in CR, 16% had a CR pre-ASCT, 72% had a lesser response, and 9% were chemo-resistant. The addition of R to salvage (23/84 pts) was favorably associated with ORR after ASCT (OR: 5.2, 95% CI: 1.1 - 25, p=0.029), even in pts who had failed a prior R regimen (p=0.013). Other factors favorably associated with ORR were response to salvage (p=0.046) and time to ASCT >12 mos (p=0.017). At last f/u (med: 22 mos, iqr: 7 - 55 mos), event-free (EFS) and overall survival (OS) were both 35%. The only factor associated with EFS and OS in univariate and multivariate analyses was ORR after ASCT (HR: 0.16, 95% CI: 0.07 - 0.37, p<0.001 and HR: 0.12, 95% CI: 0.05 - 0.28, p<0.001 respectively). Age at ASCT, time to ASCT, year of ASCT, mobilization/conditioning regimen, and failure of a R-chemo regimen were not associated with EFS or OS. Conclusions: Pts with DLBCL who have failed a R-chemo first-line regimen derive an equal benefit from ASCT as pts who are R-naïve, with significant long-term EFS and OS. Additionally, inclusion of R in salvage therapy prior to ASCT provides superior response rates, even after a failed prior R-chemo regimen. These results confirm the benefit of ASCT for pts with DLBCL in the rituximab era and argue for the incorporation of R and related agents in studies of high-dose therapy and ASCT.

No significant financial relationships to disclose.

Estimates of the health risk reductions associated with attainment of alternative particulate matter standards in two U.S. cities

As part of its periodic re-evaluation of particulate matter (PM) standards, the U.S. Environmental Protection Agency estimated the health risk reductions associated with attainment of alternative PM standards in two locations in the United States with relatively complete air quality data: Philadelphia and Los Angeles. PM standards at the time of the analysis were defined for particles of aerodynamic diameter less than or equal to 10 microm, denoted as PM-10. The risk analyses estimated the risk reductions that would be associated with changing from attainment of the PM-10 standards then in place to attainment of alternative standards using an indicator measuring fine particles, defined as those particles of aerodynamic diameter less than or equal to 2.5 microm and denoted as PM-2.5. Annual average PM-2.5 standards of 12.5, 15, and 20 microg/m3 were considered in various combinations with daily PM-2.5 standards of 50 and 65 microg/m3. Attainment of a standard or set of standards was simulated by a proportional rollback of "as is" daily PM concentrations to daily PM concentrations that would just meet the standard(s). The predicted reductions in the incidence of health effects varied from zero, for those alternative standards already being met, to substantial reductions of over 88% of all PM-associated incidence (e.g., in mortality associated with long-term exposures in Los Angeles, under attainment of an annual standard of 12.5 microg/m3). Sensitivity analyses and integrated uncertainty analyses assessed the multiple-source uncertainty surrounding estimates of risk reduction.

Relationship between acute morphine and the course of PTSD in children with burns

OBJECTIVE

To investigate the relationship between the dose of morphine administered during a child's hospitalization for an acute burn and the course of posttraumatic stress disorder (PTSD) symptoms over the 6-month period following discharge from the hospital.

METHOD

Twenty-four children admitted to the hospital for an acute burn were assessed twice with the Child PTSD Reaction Index: while in the hospital and 6 months after discharge. The Colored Analogue Pain Scale was also administered during the hospitalization. All patients received morphine while in the hospital. The mean dose of morphine (mg/kg/day) was calculated for each subject through chart review.

RESULTS

The Pearson product moment correlation revealed a significant association between the dose of morphine received while in the hospital and a 6-month reduction in PTSD symptoms. Children receiving higher doses of morphine had a greater reduction in PTSD symptoms over 6 months.

CONCLUSIONS

This study suggests the possibility that acute treatment with morphine can secondarily prevent PTSD. This result is discussed in terms of the possible effect of morphine on fear conditioning and the consolidation of traumatic memory.

Some considerations concerning multimedia-multipollutant risk assessment methodology: use of epidemiologic data for non-cancer risk assessment in Russia

The highly industrialized small town of Verkhnyaya Pyshma (in the Urals region of Russia) was chosen as the site of a multimedia-multipollutant risk assessment using the U.S. Environmental Protection Agency methodology. The assessment was based on routine environmental pollution monitoring data for ambient air, soils, drinking water, and food, and the international environmental epidemiology literature. Using an a priori set of the preliminary health-based criteria, we selected nine pollutants for risk assessment: total suspended particles (TSP), sulfur dioxide, nitrogen dioxide, benzo(a)pyrene (BaP), ammonia arsenic, copper, cadmium, and lead. We used dose-response functions derived from epidemiologic studies to assess individual and population risks for TSP, SO2, NO2, As, Cd, and Pb. We assessed both cancer (for BaP, As, and Cd) and non-cancer (for all the chosen pollutants but BaP) responses, but in this paper we discuss only the assessments of noncarcinogenic risks due to TSP, SO2, NO2, Pb, and Cd as examples of how the quantitative estimates of health effects can be produced by using a risk function approach. We also schematically present a modified conceptual model of multimedia-multipollutant risk assessment taking into account the experience gained with this study.

A DNase I hypersensitive site near the murine gamma1 switch region contributes to insertion site independence of transgenes and modulates the amount of transcripts induced by CD40 ligation

Several cis-acting elements regulate the expression of germline transcripts of heavy chain constant region genes and their subsequent switch recombination. To study such elements in the murine gamma1 gene, we have utilized a transgenic approach. In this study we focused on a DNase I hypersensitive site (termed 'Site II') that lies about 2 kb 3' of the gamma1 promoter region and I exon, just 5' to the gamma1 switch region. We have reported that gamma1 transgenes with Site II display the characteristics of a locus control region (LCR) in that they are insertion site independent and copy number dependent. For the present study we prepared six lines of transgenic mice that have the promoter region and I exon, but lack Site II. Expression of RNA from gamma1 transgenes that lack Site II is not correlated with transgene copy number; expression is insertion site dependent. This result indicates that DNase hypersensitive Site II is an important part of the LCR-like elements in the murine gamma1 gene. RNA expression from the gamma1 transgenes that lack Site II is inducible by IL-4 and by CD40 ligation. However, the induction of transgenic RNA expression by CD40 ligation is greater than expected, suggesting that elements within Site II participate in negative regulation of the amount of germline transcripts after CD40 ligation.

CIKS, a connection to Ikappa B kinase and stress-activated protein kinase

Pathogens, inflammatory signals, and stress cause acute transcriptional responses in cells. The induced expression of genes in response to these signals invariably involves transcription factors of the NF-kappaB and AP-1/ATF families. Activation of NF-kappaB factors is thought to be mediated primarily via IkappaB kinases (IKK), whereas that of AP-1/ATF can be mediated by stress-activated protein kinases (SAPKs; also named Jun kinases or JNKs). IKKalpha and IKKbeta are two catalytic subunits of a core IKK complex that also contains the regulatory subunit NEMO (NF-kappaB essential modulator)/IKKgamma. The latter protein is essential for activation of the IKKs, but its mechanism of action is not known. Here we describe the molecular cloning of CIKS (connection to IKK and SAPK/JNK), a previously unknown protein that directly interacts with NEMO/IKKgamma in cells. When ectopically expressed, CIKS stimulates IKK and SAPK/JNK kinases and it transactivates an NF-kappaB-dependent reporter. Activation of NF-kappaB is prevented in the presence of kinase-deficient, interfering mutants of the IKKs. CIKS may help to connect upstream signaling events to IKK and SAPK/JNK modules. CIKS could coordinate the activation of two stress-induced signaling pathways, functions reminiscent of those noted for tumor necrosis factor receptor-associated factor adaptor proteins.

Moving beyond the illness: factors contributing to gaining and maintaining employment

The work presented here, exploratory in nature, uses a comparative and qualitative approach to understand the factors associated with the ability of individuals with severe and persistent mental illness to successfully gain and maintain employment. Based on open-ended interviews with individuals in an Assertive Community Treatment (ACT) program, we compare the experiences of those who have been successful gaining and maintaining employment, with those who have been successful gaining but not maintaining work, and those who have been unsuccessful gaining employment. The three groups seemed to differ in three significant ways: (1) in the ways the individuals talked about their illness, (2) in the ways the individuals talked about work, and (3) in the strategies they described for coping with bad days. In each of these areas individuals' awareness of and attitude toward their illness was significant. The findings have clear implications for agencies working to help people with severe and persistent mental illness obtain and maintain employment.

Airbag associated fatal head injury: case report and review of the literature on airbag injuries

Airbags have been shown to significantly reduce mortality and morbidity in motor vehicle crashes. However, the airbag, like the seat belt, produces its own range of injuries. With the increasing use of airbags in the UK, airbag associated injuries will be seen more often. These are usually minor, but in certain circumstances severe and fatal injuries result. Such injuries have been described before in the medical literature, but hitherto most reports have been from North America. This is the first case report from the UK of serious injury due to airbag deployment and describes the case of a driver who was fatally injured when her airbag deployed in a moderate impact frontal collision where such severe injury would not normally have been anticipated. The range of airbag associated injuries is described and predisposing factors such as lack of seat belt usage, short stature, and proximity to airbag housing are discussed. The particular dangers airbags pose to children are also discussed.

Distinct activities of p52/NF-kappa B required for proper secondary lymphoid organ microarchitecture: functions enhanced by Bcl-3

Mice rendered deficient in p52, a subunit of NF-kappa B, or in Bcl-3, an I kappa B-related regulator that associates with p52 homodimers, share defects in the microarchitecture of secondary lymphoid organs. The mutant mice are impaired in formation of B cell follicles and are unable to form proper follicular dendritic cell (FDC) networks upon antigenic challenge. The defects in formation of B cell follicles may be attributed, at least in part, to impaired production of the B lymphocyte chemoattractant (BLC) chemokine, possibly a result of defective FDCs. The p52- and Bcl-3-deficient mice exhibit additional defects within the splenic marginal zone, including reduced numbers of metallophilic macrophages, reduced deposition of the laminin-beta 2 chain and impaired expression of a mucosal addressin marker on sinus-lining cells. Whereas p52-deficient mice are severely defective in all of these aspects, Bcl-3-deficient mice are only partially defective. We determined that FDCs or other non-hemopoietic cells that underlie FDCs are intrinsically impaired in p52-deficient mice. Adoptive transfers of wild-type bone marrow into p52-deficient mice failed to restore FDC networks or follicles. The transfers did restore metallophilic macrophages to the marginal zone, however. Together, the results suggest that p52 carries out functions essential for a proper splenic microarchitecture in both hemopoietic and non-hemopoietic cells and that Bcl-3 is important in enhancing these essential activities of p52.

Germline transcription and recombination of a murine VDJmudeltagamma1 transgene

To investigate the regulation of Ig switch recombination, we have constructed mice with a 56 kb VDJmudeltagamma1 transgene. This transgene included an anti-nitrophenyl VDJ segment, Smu, Cmu, Cdelta, Igamma1, Sgamma1, Cgamma1 and the Cgamma1 membrane exons from the murine Igh(a) haplotype. Two founder lines were produced, with very similar characteristics. Transgenic B cells expressed normal amounts of Cmu (which is >95% transgenic), Cdelta and other cell surface markers, and normal amounts of VDJ and Cmu RNA. Gamma1 germline transcription of the transgenes is properly regulated since stable transcripts were not expressed in B cells treated with lipopolysaccharide (LPS) alone, nor in thymus or non-lymphoid tissues, but were expressed after treatment of B cells with LPS + IL-4 or CD40L + IL-4. B cells from both lines of transgenic mice expressed transgenic gamma1a after in vitro culture with CD40L + IL-4, but not after culture with CD40L alone. However, the CD40L + IL-4 induced IgG1 precursor frequency is much lower for VDJmudeltagamma1 transgenic B cells (1:240-760) than for non-transgenic B cells (1:9). Analysis of DNA from transgenic hybridomas indicated that switch recombination can take place in switch (S) regions, but can also take place outside S regions. These results indicate that targeting of switch recombinase to S regions must include regulation beyond the S regions themselves and correct germline transcription. This additional regulation might include cis-acting elements or appropriate spacing or arrangement of the recombining elements.

Potential regulatory elements for germline transcription in or near murine Sgamma1

We were interested in identifying cis-acting elements that regulate germline transcription and switch recombination of heavy chain genes. The murine gamma1 heavy chain gene includes two DNase I hypersensitive sites, which may represent protein:DNA interactions important for germline transcription and switch recombination. One DNase hypersensitive site is at the promoter/I exon boundary (termed 'Site I'); we localized a second pair of DNase hypersensitive sites to just 5' of the Sgamma1 region (termed 'Site II'). The DNA region of hypersensitive Site II includes a NF-kappaB/Rel binding site and a STAT6 binding site. It is noteworthy that NF-kappaB and STAT6 are induced by the same agents (CD40 ligation and IL-4 respectively) that stimulate germline transcription and switch recombination of the murine gamma1 gene. Transgenes with the gamma1 promoter region (DNase hypersensitive Site I), Igamma1 and DNase I hypersensitive Site II expressed germline transcripts with correct regulation, including IL-4 inducibility. However, the level of stable transcripts produced by the transgenes was much lower than that of the endogenous gamma1 gene, a complete 17 kb gamma1 transgene or a derivative of the 17 kb gamma1 transgene that lacked most of Cgamma1. The promoter/Igamma1/Site II transgenes lacked Sgamma1 and we found that gamma1 transgenes that lacked only Sgamma1 also expressed germline transcripts with proper regulation, but at a low level. This suggested that the Sgamma1 region includes positive elements for regulation of the amount of germline transcripts.

Ovarian abscess 15 months after vaginal hysterectomy. A case report

BACKGROUND

Ovarian abscess is a primary infection of ovarian parenchyma. Since 1869, only 44 cases after vaginal hysterectomy have been reported in the medical literature. The pathophysiology of bacterial infection in these cases is different from the traditional ascending mechanism.

CASE

A 28-year-old woman presented with complaints of lower abdominal pain and fever 15 months after transvaginal hysterectomy. Her white blood cell count was 22,700/mm3, with 90% neutrophils. Bimanual examination revealed a tender mass in the cul-de-sac, and computed tomography showed a large, multiloculated pelvic mass. Laparotomy, pathologic examination and microbiologic study confirmed the diagnosis of ovarian abscess.

CONCLUSION

Our case represents another rare posthysterectomy ovarian abscess. Most of these cases were managed by surgery and antibiotic treatment.

Enhanced ex vivo cosedimentation of high molecular weight neurofilament protein (NFH) with microtubules following in vivo aluminum chloride exposure: inhibition of dephosphorylation-dependent dissociation

We have investigated the effect of acute in vivo aluminum exposure on the subsequent ex vivo cross-linking of the high molecular weight neurofilament protein (NFH) with polymerized microtubules. Young adult female New Zealand white rabbits were inoculated intracisternally with 1000 micrograms of AlCl3 in 0.9% NaCl or with 0.9% NaCl alone, and killed 48 hours later. Following isolation of a cytoskeletal-enriched protein fraction from the cervical spinal cord, NFH was purified by either electroelution or column chromatography. Tubulin was isolated from New Zealand white rabbit brains by repeated temperature-dependent polymerization and depolymerization, purified over phosphocellulose, and cosedimented with either phosphorylated or dephosphorylated NFH. Following incubation for 30 minutes at 32 degrees C with tubulin in the presence of 20 microM Taxol, 1.0 mM MgCl2 and 1.0 mM GTP, the insoluble pellet containing NFH/microtubules was isolated. Both the pellet and supernatent were fractionated by SDS.PAGE and the amount of NFH present quantified by transmission densitometry following silver-staining. Results were identical regardless of the technique utilized for the purification of NFH. Control NFH preferentially cosedimented with microtubules when in the fully phosphorylated isoform, but remained in the soluble fraction following dephosphorylation. Phosphorylated NFH derived from AlCl3-inoculated rabbits demonstrated similar binding characteristics to control NFH, but following exhaustive dephosphorylation, exhibited a 4.5 fold induction of NFH/microtubule binding (p = 0.0314). Incubating dephosphorylated control NFH with microtubules in the presence of increasing concentrations of AlCl3 failed to induce similar cosedimentation. These experiments suggest that phosphorylation promotes NFH cross-linking to microtubules. In addition, the phosphorylation/dephosphorylation dependent regulation of NFH cross-linking to microtubules is disrupted following in vivo AlCl3 exposure by a mechanism that s independent of NFH/Al3+ binding.

Informed consent from whom?

To obtain legally safe informed consent requires that the patient has a 'substantial understanding' of the proposed procedure and that the doctor obtaining the informed consent has sufficient knowledge to explain the nature of the procedure to the patient. In this paper we have shown that significant misunderstanding exists among non-specialist junior doctors of certain common orthopaedic procedures and conditions. Junior doctors often lack sufficient technical training to fully inform their patients and thus meet legal requirements. The implications of this are that the onus falls even more on specialists to ensure that their patients receive a more detailed explanation of the proposed intervention.

A personal account of workplace violence from a nursing perspective

The author describes the incident that changed her life--when she was taken hostage by a psychiatric patient. She discusses the healing process and why healthcare workers must be aware of the potential for violence.

Effects of gentle human touch on preterm infants: pilot study results

A pilot study was conducted to evaluate the effects of gentle human touch (GHT) provided for 15 minutes a day to preterm infants from day 7 to day 12 of life. The study suggested that GHT has no adverse effects on the oxygen saturation or heart rate levels of small preterm infants and that GHT has a soothing effect as evidenced by decreased levels of active sleep, motor activity, and behavioral distress. These results can provide NICU nurses with a basis for guiding parents in their early interactions with preterm infants in the NICU.

A new form of polyagglutination related to Cad

Four phenotypes of Cad (Cad 1-4) have been characterized by a continuum of polyagglutinability and reactivity with lectins, with the strongest Cad+ red blood cells (RBCs) being polyagglutinable because of the presence of anti-Cad (anti-Sda) in most normal sera. Over a period of 7 years, a French male blood donor's RBCs demonstrated polyagglutinability with 50 percent to 70 percent of normal adult sera. The reactivity was characteristic of anti-Sda (refractile agglutination at 4 degrees C, 20 degrees C, 37 degrees C, and anti-human globulin test), and was inhibitable by two examples of Sd(a+) urine, but not by Sd(a-) urine or dialysate from Sd(a+) urine. The donor's RBCs reacted 1+ with Glycine max, but did not react with Dolichos biflorus, Leonurus cardiaca, Salvia horminum, or Arachis hypogaea. The first four of these lectins were reactive with five of five Cad+ RBCs, including one example of Cad 4 RBCs. Polybrene(R) aggregated the donor RBCs. Dilutions of nine samples of anti-Sda reacted more strongly with the donor RBCs than with normal RBCs. Even though lectin studies failed to classify this donor's RBCs as Cad, the persistent polyagglutinability and serologic characteristics are consistent with Cad and demonstrate the heterogeneity of this antigen.

Precision and accuracy of clinical and radiological signs in premature infants at risk of patent ductus arteriosus

OBJECTIVE

To determine the precision (interobserver agreement) and accuracy (agreement with criterion standard) of clinical and radiological signs in premature infants at risk of patent ductus arteriosus (PDA) with left-to-right shunting.

DESIGN

Masked comparison of clinical and radiological examination with Doppler flow echocardiography (criterion standard).

SETTING

Neonatal intensive care unit.

PATIENTS

One hundred infants with birth weights less than 1750 g were studied once between days 3 and 7 of life. A third of the cohort was intubated at the time of study.

INTERVENTION

Five independent observers noted the presence or absence of an increased pulse volume, an active precordium, a heart murmur, a cardiothoracic ratio greater than 60%, increased pulmonary vascular markings on a concurrent chest x-ray film, and a relative increase of the cardiothoracic ratio compared with that from the previous chest x-ray film. Pulsed and color flow Doppler echocardiography was performed within 4 hours. All 100 tapes were reviewed by a second pediatric cardiologist.

RESULTS

Twenty-three infants had a PDA with left-to-right shunting. The precision of clinical signs was modest, with average kappa values of 0.15 for pulse volume, 0.32 for precordium, and 0.41 for murmur. Pulse quality (43%) and murmur (42%) had the highest mean sensitivities. Corresponding specificities were 74% for pulse volume and 87% for murmur. The combination of a cardiac murmur with an abnormal pulse volume had the highest positive predictive value (77%). The radiological examination did not improve the observers' ability to distinguish between patients with and without PDA.

CONCLUSIONS

The precision and accuracy of clinical and radiological signs of a PDA with left-to-right shunting are unsatisfactory. Therefore, Doppler flow echocardiography is required to diagnose PDA confidently in preterm infants between days 3 and 7 of life.

Elevation in anti-Proteus antibodies in patients with rheumatoid arthritis from Bermuda and England

OBJECTIVE

To determine whether patients with rheumatoid arthritis (RA) from Bermuda and England have an increased anti-Proteus antibody titer when compared to healthy Bermudian and English controls, and to ascertain whether any increase in antibody titer is specific by testing 4 other microbes, Escherichia coli and 3 normal anaerobic bowel bacteria.

METHODS

Antibody titers were measured by ELISA and indirect immunofluorescence (IIFA) under coded conditions.

RESULTS

Elevated titers of anti-Proteus antibodies were demonstrated in 34 patients with active RA from Bermuda when compared to 33 healthy Bermudian controls by ELISA (p < 0.001) and IIFA (p < 0.001). An elevation of anti-Proteus antibodies was also observed in 34 patients with RA from England when compared to 30 healthy English controls again by ELISA (p < 0.001). A similar antibody elevation in 31 patients with RA from England was observed when compared to 30 healthy controls when measured by IIFA (p < 0.001). However, there was no significant elevation in antibody titers against E. coli or the 3 normal bowel flora isolates in the patients with RA from both countries compared to their respective controls, when measured by ELISA.

CONCLUSION

A specific elevation in the immune response to Proteus mirabilis has been demonstrated in patients with RA from both Bermuda and England. However, this study cannot distinguish between antibody association with disease per se and association with disease activity. The role of Proteus in RA and the effect of anti-Proteus therapy in patients with RA merits further study.

The colicin A pore-forming domain fused to mitochondrial intermembrane space sorting signals can be functionally inserted into the Escherichia coli plasma membrane by a mechanism that bypasses the Tol proteins

Colicin A is a pore-forming bacteriocin that depends upon the Tol proteins in order to be transported from its receptor at the outer membrane surface to its target, the inner membrane. The presequence of yeast mitochondria cytochrome c1 (pc1) as well as the first 167 amino acids of cytochrome b2 (pb2) were fused to the pore-forming domain of colicin A (pfColA). Both hybrid proteins (pc1-pfCoIA and pb2-pfColA) were cytotoxic for Escherichia coli strains devoid of colicin A immunity protein whereas the pore-forming domain without presequence had no lethal effect. The entire precursors and their processed forms were found entirely associated with the bacterial inner membrane and their cytotoxicities were related to their pore-forming activities. The proteins were also shown to kill the tol bacterial strains, which are unable to transport colicins. In addition, we showed that both the cytochrome c1 presequence fused to the dihydrofolate reductase (pc1-DHFR) and the cytochrome c1 presequence moiety of pc1-pfCoIA were translocated across inverted membrane vesicles. Our results indicated that: (i) pc1-pfCoIA produced in the cell cytoplasm was able to assemble in the inner membrane by a mechanism independent of the tol genes; (ii) the inserted pore-forming domain had a channel activity; and (iii) this channel activity was inhibited within the membrane by the immunity protein.

Cefuroxime axetil in the treatment of bronchitis: comparison with amoxycillin in a multicentre study in general practice patients

Cefuroxime axetil 250 mg twice daily and amoxycillin 250 mg three times daily were compared in an investigator-blind, randomised, parallel group, multicentre study of acute or acute-on-chronic bronchitis. The two compounds had broadly similar efficacy. Analysis of patients on an intention-to-treat basis 24-72 hours after completion of the course of study medication showed that amoxycillin afforded clinical cure or improvement in 123/153 (80.4%) of patients and cefuroxime axetil in 109/143 (76.2%). This result was not significantly different, but the amoxycillin cure rate was not sustained and there were significantly more clinical relapses during the 4-week follow-up period following the end of treatment. Only 4/68 (5.9%) of patients receiving cefuroxime axetil relapsed and required further treatment, whereas 16/77 (20.8%) of those receiving amoxycillin needed further treatment (P = 0.016). These were all patients who had initially responded to treatment and had been adjudged clinically cured or improved. The significant difference in relapse rates suggests that the apparent clinical success with amoxycillin was not sustained. There were no differences between the two treatments in the numbers of patients experiencing adverse events, which were generally mild and transient.

Internal carotid artery dissection after remote surgery. Iatrogenic complications of anesthesia

BACKGROUND

Subintimal dissection with acute occlusion of the internal carotid artery resulting in acute cerebral infarction has not been reported as an iatrogenic complication of general anesthesia.

CASE DESCRIPTIONS

An anesthetist stretched the neck of a 44-year-old man by anchoring an anesthesia mask posterior to the angle of the jaw with overlying fingers as the patient struggled during an insufficient inhalational mask anesthetic. A 33-year-old man received an endotracheal anesthetic without struggle, but as he was turned from a supine to a prone position, his head and neck were not immobilized to rotate with his torso during the move. The next day both patients suffered acute cerebral infarctions secondary to ICA dissections and occlusions (angiographically demonstrated).

CONCLUSIONS

Stretching the soft neck tissues of anesthetized patients can cause internal carotid artery dissection and acute cerebral infarction.

The role of the gut in regulating food intake in man

In addition to various psychosocial and metabolic factors, food intake is also influenced by gastrointestinal mechanisms that trigger both the initiation and termination of eating behaviors. Although gastric distension is one of the most obvious signs of "fullness" and clearly plays a role in controlling food intake, its effects are only temporary and are distinct from the feelings of satiety generally associated with a meal. Such postprandial sensations appear to be related to the activation of intestinal chemoreceptors. Other evidence indicates that the release of cholecystokinin and perhaps other transmitters as well may contribute to satiety. Although the stomach probably does not expand or shrink in response to different levels of food intake, nutrient receptors in the small intestine probably do adapt to changes in food intake. Intestinal adaptation also occurs in response to thyroid hormone, insulin, and cortisol as well as to obesity, pregnancy, and illness, which all may have an important bearing on changes in eating behavior in these situations.