Urinary complications of Miami pouch: trend of conservative management

OBJECTIVE

Continent urinary diversions have become popular among gynecologic oncologists. Much information has been gained concerning the complications and current management of patients with continent ileocolonic reservoirs. The high mortality rate associated with reoperation has led clinicians to adopt a trend toward conservative means of management. The purpose of this study was to evaluate the applicability of conservative management of complications related to the creation of the continent ileocolonic reservoir Miami pouch.

STUDY DESIGN

Patients who underwent creation of the Miami pouch at the Division of Gynecologic Oncology, University of Miami School of Medicine, since 1988 have been included in this study. Management of complications, with particular emphasis on the conservative treatment, has been reviewed in detail for each patient. Open surgery and conservative treatment have been compared.

RESULTS

Seventy-seven patients underwent creation of the Miami pouch from February 1988 to September 1997. Sixty (77.9%) patients were affected by recurrent cervical cancer; 72 (93.5%) were previously radiated. The perioperative mortality rate was 11.7% (9 patients). Six of these patients died as a result of sepsis; all of them underwent reoperation at least once. The most common urinary complications were ureteral stricture or obstruction (22.1%), difficult catheterization (19.5%), and pyelonephritis (13%). Conservative management strategies used for these complications included percutaneous nephrostomy, stent placement, balloon dilatation, radiologically (ultrasonography, fluoroscopy, computed tomography) guided placement of catheters, and antibiotic treatment. Eighty percent of the complications associated with the ileocolonic reservoir were resolved with conservative treatment, whereas 16.9% required surgical revision.

CONCLUSION

On the basis of these findings, conservative management of urinary reservoir complications should always be considered before surgical intervention is attempted. The exact time to engage in open revision should be individualized on the basis of the clinical condition of each patient. It is our belief that the conservative approach should be instituted whenever possible but surgical intervention not be delayed when absolutely indicated.

Effect of genotypes on the quantification of hepatitis C virus (HCV) RNA in clinical samples using the Amplicor HCV Monitor Test and the Quantiplex HCV RNA 2.0 assay (bDNA)

The Amplicor HCV Monitor test and the Quantiplex HCV RNA 2.0 (bDNA) assay are two commercially available assays for the quantification of hepatitis C virus (HCV) RNA in clinical samples. A direct comparison of the two assays was carried out using sera frozen previously from patients known to be chronically infected with HCV. Overall, 61 samples from 51 patients were tested simultaneously by the two methods: 67% (28/42) of the patients were infected by HCV genotype/serotype 1, 10% (4/42) with type 2, and 24% (10/42) with type 3. When the absolute value from each assay was examined, the Quantiplex assay gave a consistently higher reading and the mean logarithmic difference between the two assays was 1.4 (1.0 in type 1, 2.0 in type 2, and 2.2 in type 3). When analyzed according to genotype, strong correlation was observed between the two assays for type 1 (r = 0.83, 95% CI 0.63-0.93, P < 0.01), but not for nontype 1 samples. Despite the difference in absolute level reported by the two assays, there was a consistent trend of change in HCV RNA concentration by both assays in patients whose consecutive samples were analyzed and the differences between the two assays in consecutive samples were within 0.4 log of each other. The results suggested that with samples containing genotype 1, the Amplicor assay was more sensitive than the Quantiplex assay by about one log. However, the sensitivities of the two assays with nontype 1 samples were much closer probably due to the failure of the Amplicor assay to quantify nontype 1 genotypes effectively.

Alternative Splicing of Human NrCAM in Neural and Nonneural Tissues

Neural cell adhesion molecule NrCAM exists in a variety of isoforms as a result of alternative splicing of individual exons during RNA processing. In this report we demonstrate that many of the alternative splicing events described for chick are conserved in man and describe a novel variant of NrCAM cDNA. Furthermore, we show that NrCAM is expressed at significant levels outside the nervous system; in particular in pancreas, adrenal glands, and placenta and that expression in both brain and other tissues is accompanied by a very variable pattern of exon utilization in fetal and adult cells. Copyright 1998 Academic Press.

Gamma-hydroxybutyrate (GHB): a new drug of misuse

Accident and Emergency Departments offer a unique opportunity for identifying and monitoring new drugs of misuse. This series of six case reports describes the potentially serious medical complications associated with the use of gamma-hydroxybutyrate (GHB) a new drug of misuse on the UK scene. Profound unconsciousness occurred in all cases and despite full (and often rapid) recovery all patients required medical intervention. Adverse effects occurred both when GHB was used alone or in combination with other illicit drugs and alcohol.

Recognition of dermatological conditions by junior doctors on general medical wards

Although we know something about the prevalence of various dermatological conditions in the community, virtually nothing is known about the prevalence and type of skin conditions affecting general medical patients in hospital. This has important implications for both undergraduate training and the continuing education of junior doctors about common skin disorders. In this study we examine the prevalence of skin conditions in 100 in-patients on four general medical wards, and assess the awareness and diagnostic accuracy of junior doctors encountering common dermatological conditions in their patients. Forty-six patients had one or more skin conditions, excluding seborrhoeic warts, skin tags, benign pigmented naevi and Campbell De Morgan spots. The 16 junior doctors correctly diagnosed 64% of common skin conditions that should have been covered in the undergraduate curriculum but detected only 43% of the two malignant skin lesions (basal cell carcinomas) identified in the study. The presence of skin conditions was rarely recorded in the notes, even when the condition was potentially relevant to the general medical condition of the patient. This study highlights the need for greater awareness of skin disease amongst junior doctors in order to avoid unnecessary patient morbidity.

Community validation of the United Kingdom diagnostic criteria for atopic dermatitis in Romanian schoolchildren

Although the U.K. modification of Hanifin and Rajka's diagnostic criteria for atopic dermatitis (AD) for use in epidemiological studies has demonstrated good validity and repeatability when previously tested in a U.K. community setting, little is known about its performance in other countries where different cultural, educational and linguistic factors could impair validity. We used a questionnaire to test the validity of the U.K. criteria as a point prevalence measure of AD in 1114 Romanian schoolchildren aged 6-12 years against the clinical diagnosis of a dermatologist with an interest in AD, who was unaware of the questionnaire content and responses. The sensitivity and specificity of the U.K. criteria for AD in this setting was 74% and 99%, respectively, an improvement rather than a deterioration in validity when compared with the previous U.K. study. Test-retest repeatability for all of the questions pertaining to the U.K. criteria using the chance-corrected kappa statistic was high, with values of 0.72 and over. The positive predictive value of the criteria was lower than in the U.K. study (63% compared with 80%, respectively) due to the very low prevalence of AD in this study (2.4%). The validity of a parental report of 'eczema' was poor, with a sensitivity of 22%, specificity of 97% and positive predictive value of 18%. This study suggests that the U.K. criteria perform well in settings outside the U.K., although care has to be taken when using the criteria to ascertain cases in settings where the prevalence of AD is very low.

Hemobilia due to hepatic artery pseudoaneurysm thirteen months after laparoscopic cholecystectomy

Although vascular complications following laparoscopic cholecystectomy are rare, hemobilia may occur within the first 4 weeks after surgery. We report a 57-year-old woman with hemobilia secondary to a pseudoaneurysm of the right hepatic artery presenting 13 months after laparoscopic cholecystectomy. To our knowledge, such late presentation has never before been reported.

Anesthetic techniques and positioning: implications for perioperative nurses

Depending on the anesthetic technique used and the position in which the patient is placed, the perioperative nurse knowledgeable in the implications of each technique will positively impact patient safety and management. This involves a thorough understanding of the systems affected and associated risks. Whether general anesthesia, regional anesthesia, or monitored anesthesia care is provided, specific actions by the nurse facilitates teamwork.

Hepatitis G virus RNA and its relation to hepatitis C infection in adult haemophilic patients

The prevalence of hepatitis C virus (HCV) infection and hepatitis G virus (HGV) RNA were studied in 50 adult haemophilic patients who had received commercial clotting factors prior to 1980. HGV RNA was detectable in 6/ 50 patients (12%); 49/50 (98%) had antibody to HCV and 40/49 (82%) of these were viraemic with detectable HCV RNA; 5/6 patients with detectable HGV RNA had co-existing HCV infection and viraemia. The HGV PCR products from all six patients were directly sequenced and all were shown to be similar to that of HGV but more diverse from that of GB virus C. One patient who had persistent abnormal liver function tests had detectable HGV RNA but no evidence of hepatitis B or C. The presence of HGV RNA in the absence of hepatitis B and C infection indicates that this virus is capable of independent transmission. Independent response to interferon was demonstrated in one patient with co-infection who lost HGV but not HCV after interferon therapy.

Worldwide variations in prevalence of symptoms of allergic rhinoconjunctivitis in children: the International Study of Asthma and Allergies in Childhood (ISAAC)

BACKGROUND

As part of the International Study of Asthma and Allergies in Childhood (ISAAC), prevalence surveys were conducted among representative samples of school children from locations in Europe, Asia, Africa, Australia, North and South America.

SUBJECTS

257,800 children aged 6-7 years from 91 centres in 38 countries, and 463,801 children aged 13-14 years from 155 centres in 56 countries.

METHODS

Written symptom questionnaires were translated from English into the local language for self-completion by the 13-14-year-olds and completion by the parents of the 6-7-year-olds. Rhinitis was described as a problem with sneezing, or a runny, or blocked nose when you (your child) DID NOT have a cold or the flu. Additional questions were asked about rhinitis associated with itchy-watery eyes, interference with activities and a history of hay fever ever.

RESULTS

The prevalence of rhinitis with itchy-watery eyes ("rhinoconjunctivitis") in the past year varied across centres from 0.8% to 14.9% in the 6-7-year-olds and from 1.4% to 39.7% in the 13-14-year-olds. Within each age group, the global pattern was broadly consistent across each of the symptom categories. In centres of higher prevalence there was great variability in the proportion of rhinoconjunctivitis labelled as hay fever. The lowest prevalences of rhinoconjunctivitis were found in parts of eastern Europe, south and central Asia. High prevalences were reported from centres in several regions.

CONCLUSION

These results suggest substantial worldwide variations in the prevalence and labelling of symptoms of allergic rhinoconjunctivitis which require further study. These differences, if real, may offer important clues to environmental influences on allergy.

Compression of nucleotide databases for fast searching

MOTIVATION

International sequencing efforts are creating huge nucleotide databases, which are used in searching applications to locate sequences homologous to a query sequence. In such applications, it is desirable that databases are stored compactly, that sequences can be accessed independently of the order in which they were stored, and that data can be rapidly retrieved from secondary storage, since disk costs are often the bottleneck in searching.

RESULTS

We present a purpose-built direct coding scheme for fast retrieval and compression of genomic nucleotide data. The scheme is lossless, readily integrated with sequence search tools, and does not require a model. Direct coding gives good compression and allows faster retrieval than with either uncompressed data or data compressed by other methods, thus yielding significant improvements in search times for high-speed homology search tools.

Epstein-Barr virus induced virus-associated hemophagocytic syndrome and monoclonal TCR-beta rearrangement: a case report

Virus-associated hemophagocytic syndrome (VAHS) is a rare histiocytic proliferative disorder secondary to viral infection affecting children and young adults and in which there is both a poor prognosis and no specific treatment. We report a case of VAHS in a 22-year-old woman secondary to infection with Epstein Barr virus in which multiorgan failure developed with a fatal outcome 3 weeks after presentation. Clonal analysis showed EBV incorporation into the T cell genome accompanied by monoclonal rearrangement of the TCR beta gene. Treatment with cyclosporin A resulted in hematological improvement but the patient died of disseminated fungal infection. We propose that bone marrow ablation and allografting should be available for these rare cases and suggest that a protocol should be developed with designated transplant centres to aid early referral.

Consensus chemistry and beta-turn conformation of the active core of the insect kinin neuropeptide family

BACKGROUND

Neuropeptides are examples of small, flexible molecules that bind to receptors and induce signal transduction, thereby eliciting biological activity. The multifunctional insect kinin neuropeptides retain full activity when reduced to only their carboxy-terminal pentapeptide (Phe1-X2-X3-Trp4-Gly5-NH2), thereby allowing extensive structure-function studies and conformational analysis.

RESULTS

A combined experimental and theoretical analysis of the insect kinin carboxy-terminal pentapeptide was used to probe the role of each residue, define the bioactive conformation, and design a constrained bioactive analog. Coupling receptor-binding data with two biological activity assays allowed receptor binding and signal transduction to be differentiated. A preferred beta-turn conformation, found for residues 1-4 by molecular dynamics simulations, was tested by designing a conformationally restricted cyclic hexapeptide. This cyclic analog showed a preference for the beta-turn conformation, as shown by a conformational search and nuclear magnetic resonance spectroscopy, and it showed stronger receptor binding but decreased activity relative to highly active linear analogs.

CONCLUSIONS

Each residue of the insect kinin carboxy-terminal pentapeptide has a distinct role in conformational preference, specific receptor interactions or signal transduction. The beta-turn preference of residues Phe1-X2-X3-Trp4 implicates this as the bioactive conformation. The amidated carboxyl terminus, required for activity in many neuropeptide families, may be generally important for signal transduction and its inclusion may therefore be essential for agonist design.

Feasibility and effects of nurse run clinics for patients with epilepsy in general practice: randomised controlled trial. Epilepsy Care Evaluation Group

OBJECTIVE

To test the feasibility and effect of nurse run epilepsy clinics in primary care.

DESIGN

A randomised controlled trial of nurse run clinics versus "usual care."

SETTING

Six general practices in the South Thames region.

SUBJECTS

251 patients aged over 15 years who were taking anti-epileptic drugs or had a diagnosis of epilepsy and an attack in the past two years who met specified inclusion criteria and had responded to a questionnaire.

MAIN OUTCOME MEASURES

Questionnaire responses and recording of key variables extracted from the clinical records before and after the intervention.

RESULTS

127 patients were randomised to a nurse run clinic, of whom 106 (83%) attended. The nurse wrote 28 letters to the general practitioners suggesting changes in epilepsy management. For this intervention group compared with the usual care group there was a highly significant improvement in the level of advice recorded as having been given on drug compliance, adverse drug effects, driving, alcohol intake, and self help groups.

CONCLUSIONS

Nurse run clinics for patients with epilepsy were feasible and well attended. Such clinics can significantly improve the level of advice and drug management recorded.

Correlation between self-reported cocaine use and urine toxicology in an inner-city prenatal population

To determine the prevalence of recent cocaine use and the accuracy of self-reported use, the results of a urine assay for the major cocaine metabolite benzoylecgonine were compared with self-reported cocaine use in an inner-city prenatal population offered routine voluntary urine toxicology screening at the time of registration for prenatal care. During a 1-year period, 6866 women registered for prenatal care and 5200 (76%) consented to urine assays for cocaine metabolites. Of the women consenting to urine assays, 253 (5%) had positive assays for benzoylecgonine. Women with positive assays were significantly more likely than those with negative assays to be older (mean [SD] 27 [5] versus 23 [6] years), black, single, and unemployed. In addition, women with positive assays were significantly more likely to be multiparous, report > two sexual partners in the previous year, and acknowledge a history of a sexually transmitted disease (STD). Forty-seven percent of women with positive assays acknowledged cocaine use in the 6 months prior to sampling. Women with positive assays who denied cocaine use were significantly more likely than those who admitted use to be younger (mean [SD] 26 [5] versus 28 [4] years), to report > or = two sexual partners in the past year, and acknowledge a history of an STD. This analysis revealed a poor correlation between self-reported cocaine use and the results of urine assays for cocaine metabolites among women seeking prenatal care in an inner-city institution.

Instar susceptibility of the monarch butterfly (Danaus plexippus) to the neogregarine parasite, Ophryocystis elektroscirrha

The susceptibility of the monarch butterfly (Danaus plexippus) larvae to the neogregarine parasite, Ophryocystis elektroscirrha, was tested in the laboratory. Spore loads recovered from infected monarch butterflies were directly related to the inoculum level, larval stage of the host, and spore age. There was a linear relationship between spores ingested by first instar larvae and spore concentration. Larvae feeding on leaves treated with 0, 50, 500, 5000, or 50,000 spores averaged 0, 0, 193, 457, or 1,255 spores, respectively, on the abdomens of the adult butterflies. When first, third, and fifth instar larvae were given 14.5 spores/mg of body weight, there was no significant difference in the spore load of the adults resulting from the first and third instars. However, there were significant differences in the spore load from adults resulting from the first and third instars versus the fifth instar. In addition, 1-year-old spores were not as infectious as fresh spores. Our findings indicate that under field conditions, the first instar is most likely to become infected because one spore appears sufficient to produce a detectable spore load in the adult. Older instars are less susceptible and have fewer opportunities to encounter sufficient viable spores for infection to occur. Thus, vertical transmission appears to be the primary mode of parasite maintenance in natural populations of monarch butterflies.

Chronic recurrent multifocal osteomyelitis: spinal involvement and radiological appearances

We report a case of chronic recurrent multifocal osteomyelitis which presented as back pain in a 14-yr-old male. The full distribution of the spinal lesions was determined by MRI, which proved to be more sensitive than other imaging modalities. After 1 yr, in spite of a good symptomatic response to corticosteroid therapy, new MRI abnormalities had developed.