Acute tonsillitis complicated by retropharyngeal and thyroid abscess infected with de-repressed beta lactamase Citrobacter mutans

An unusual presentation of acute tonsillitis complicated by retropharyngeal and thyroid abscess is reported. Spontaneous rupture of retropharyngeal abscess resulted in necrotic fistulae between the pharyngeal wall and the retropharyngeal space.

Methicillin-resistant Staphyloccocus aureus: evaluation of five selective media

This study evaluates the performance in isolating methicillin-resistant Staphylococcus aureus (MRSA) of three media: the reduced salt formulation of mannitol salt agar plus oxacillin (MMSAO); CHROMagar Staph aureus plus ciprofloxacin (CHRAC); and Halifax MRSA medium (HMO), against the previously recommended mannitol salt agar (7% salt) plus oxacillin (OMSAO) and Baird-Parker medium plus ciprofloxacin (BPC). MRSA screening swabs were plated out onto the five selective media and the plates examined at 24 and 48 h. Suspected colonies were confirmed as MRSA by detection of heat-labile DNase, coagulase and/or protein A, and by confirming resistance to methicillin. Of 719 specimens examined, 191 grew MRSA on at least one medium. The relative sensitivities of the five media at 48 h were as follows: BPC, 94%; CHRAC, 70%; OMSAO, 61%; HMO, 56%; and MMSAO, 46%. In addition, BPC gave the least number of unnecessary investigations for non-MRSA isolates. The current advantage of BPC when performing direct culture for MRSA was confirmed. The other ciprofloxacin-containing medium also produced reasonable results. Of the two mannitol salt agar media, the formulation with 7% salt gave better results. HMO proved unreliable at isolating MRSA.

Hamstrings vs. patella tendon for anterior cruciate ligament reconstruction: a randomised controlled trial

A randomised controlled trial was performed to evaluate early outcome for two types of anterior cruciate ligament reconstruction. Sixty patients undergoing cruciate reconstruction were randomized into two groups. Group PT underwent reconstruction using a patella tendon autograft, whereas Group (SG) had a semitendinosus/gracilis autograft (SG). IKDC, Lysholm, and Tegner scores, KT1000 values and muscle strength were recorded pre-operatively, at 6 months and 1 year follow up. The functional scores, activity level, muscle strength and anterior tibial translation improved in both groups. No significant difference between groups was found for any measurement at 6 months and 1 year despite adequate study power. The study indicates that the 1 year results for either technique are equally favourable.

Amniotic fluid embolus: a review of the literature

PURPOSE

To review the literature since 1979 to determine the natural history, etiology, diagnosis and potential treatment of amniotic fluid embolus (AFE).

SOURCE

English language articles and books published between June 1976 and June 1998 were identified by a computerized medline search using the title or text word amniotic fluid embolus. This same search strategy was repeated and updated to October 1999 by an independent individual using both Medline and Embase. The search was also expanded to include Science Citation Index listing Morgan's 1979 review article. All relevant publications were retrieved and their bibliographies were scanned for additional sources.

PRINCIPAL FINDINGS

Randomized controlled trials are not possible with amniotic fluid emboli. The majority of the literature consists of clinical reports combined with occasional limited reviews. Knowledge obtained from these reports suggests that amniotic fluid emboli present as a spectrum of disease that ranges from a subclinical entity to one that is rapidly fatal. Because cases are sporadic and the diagnosis is often unconfirmed, little progress has been made towards understanding its etiology or defining the risk factors. Present management is empirical and directed towards the maintenance of oxygenation, circulatory support and the correction of coagulopathy.

CONCLUSION

Amniotic fluid embolus continues to be a life-threatening but potentially reversible complication unique to pregnancy. It cannot be predicted nor prevented. Review of the literature reveals that there are no standardized investigational methods or protocols to confirm the diagnosis in suspected cases.

Equity of service: a protocol for management of children with speech problems

In an attempt to achieve equity of service, the level of consistency of speech and language therapists in making decisions about the management of children with phonological delay was examined. Six cases were created and the therapists were interviewed about their management and criteria for therapy for each case. Decisions were made about standardising practice within the team. A phonological care pathway was devised to consider the criteria outlined in the results. This pathway is now being piloted with the expectation that it will facilitate an equitable service for all children with sound system problems.

Early outcomes of supervised discharge

We have previously described the generally positive initial experiences of Supervised Discharge (SD) in a large Mental Health Trust serving a mixed inner city, suburban and rural population. This paper seeks to extend our earlier findings by reporting a longitudinal cohort study examining hospitalization before and after SD for the original sample. The main outcome measures were: renewal of SD; time spent out of hospital; survival to readmission or the end of the study period (1 April 1999). Of the 22 patients commenced on SD orders between April 1996 and October 1997, by 1 April 1999: 12 patients were still subject to supervised discharge; 15 had not been readmitted to hospital; survival out of hospital was longer--717 days, compared with 607 days in the same period before SD (p = 0.037); survival to readmission was also longer than before SD (p = 0.023). Contrary to early professional expectations patients subject to SD seem to survive for longer periods in the community. Although not always effective, its wider use should at least be considered as part of the care package for detained patients with a history of non-compliance with care packages leading to relapse and readmission.

An inter-disciplinary approach to swallowing problems in acute stroke

Many speech and language therapy (SLT) departments are in danger of being swamped with dysphagia referrals, often to the detriment of other work. At the same time surveys have shown that large numbers of patients with acute stroke have swallowing problems which are poorly managed during the critical early phase, not referred or missed altogether. The Collaborative Dysphagia Audit (CODA) study, carried out in six British hospitals, showed that nurses could quickly be trained to carry out basic screening assessments for dysphagia and that implementation of a co-ordinated inter-disciplinary dysphagia management policy (DMP) could substantially improve the proportion of dysphagic patients in whom appropriate feeding precautions were taken. These early DMPs were limited by the need for ward staff to keep all patients with suspected swallowing impairment nil by mouth until assessed by SLT, so in some acute stroke units nurses have been trained to a higher level which allows them to manage most routine transient swallowing problems, leaving only complex or persistent cases for referral to SLT. This approach has been used successfully in our unit in Gateshead, where a dysphagia nurse specialist post has been set up to act as a link between ward staff and SLTs, to ensure that the necessary training levels are maintained and to co-ordinate the DMP.

Hydroxyurea for sickle cell disease

BACKGROUND

Sickle cell disease is one of the most common inherited diseases world wide. It is associated with life long morbidity and a reduced life expectancy. Hydroxyurea, a chemotherapeutic drug taken by mouth, raises fetal haemoglobin and, as such, is expected to ameliorate some of the clinical problems of sickle cell disease.

OBJECTIVES

To assess the effects of hydroxyurea therapy in sickle cell disease patients of all types, of any age, regardless of setting.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group specialised register of controlled trials for haemoglobinopathies, which comprises references identified from comprehensive electronic database searches, hand-searching relevant journals, and hand-searching abstract books of conference proceedings. Date of the most recent search(es): November 2000.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing the use of oral hydroxyurea for one month or longer with placebo, standard therapy or other interventions for the treatment of patients with sickle cell disease.

DATA COLLECTION AND ANALYSIS

Both reviewers independently assessed trial quality and extracted data from the two studies included.

MAIN RESULTS

Twenty trials were found of which two trials, which reported results from a total of 324 adults and children were suitable for inclusion in the review. From the data provided in the published reports only one study (the MSH study to the United States of America) could be analysed. This study showed marked differences in favour of hydroxyurea treatment as compared with placebo in terms of annual crisis rate, use of transfusions, and life-threatening complications (in particular, the acute sickle chest syndrome). No serious adverse effects were reported from either study.

REVIEWER'S CONCLUSIONS

While hydroxyurea appears both effective and safe in the severely affected SS adults over a two year period; further studies are required to elucidate its role in other patient groups and for other conditions.

Early screening for dyslexia--a collaborative pilot project

An ongoing collaborative project, currently being piloted in 12 Wiltshire primary schools, is described. The aim is to provide a means of identifying potentially dyslexic children by the end of Key Stage 1 (Year 2) with a view to early intervention. The causal links identified by research between phonological skills and literacy development are taken as the theoretical basis of an initial screening procedure, and an intervention package is implemented for identified children. Those demonstrating persistent difficulties one year later are further assessed over a school term using an assessment package designed to identify those children showing a dyslexic profile. Further intervention is then planned and implemented.

Regulation of endometrial cancer cell growth by luteinizing hormone (LH) and follicle stimulating hormone (FSH)

Gonadotrophin releasing hormone analogues (GnRHa) have been used to treat recurrent endometrial cancer. However, the mode of action is uncertain. Our previous studies showed no direct effect of GnRHa on endometrial cancer cell growth in vitro. We have now examined the effect of luteinizing hormone (LH) and follicle stimulating hormone (FSH) on endometrial cancer cell growth. The aim was to determine whether suppression of pituitary LH and FSH by GnRHa could explain the tumour regression seen in up to 44% of patients treated with this drug. We show that recombinant human LH and FSH (rhLH and rhFSH) produce a concentration dependent stimulation of the endometrial cancer cell line HEC-1A, in serum-free medium (maximum increase of 62 and 50% respectively relative to untreated controls). This increase is equivalent to that obtained by addition of 10% newborn calf serum. Growth of the Ishikawa cell line in culture increases in the presence of rhLH (maximum increase of 67%) but not with rhFSH. Using RT-PCR, we show that the Ishikawa cell line intermittently expresses receptor mRNA of LH but not of FSH; there is no expression of either mRNA by HEC-1A. Classically, both LH and FSH act via cAMP linked membrane receptors. However, neither rhLH nor rhFSH elicit cAMP production in either of our endometrial cancer cell lines. Thus, although a growth response to LH and FSH can be shown, and some cells express the LH receptor, stimulation appears to be via a pathway separate from that of the classical gonadotrophin receptor.

The influence of cytomegalovirus viraemia on the outcome of recurrent hepatitis C after liver transplantation

BACKGROUND

Several interrelated host and hepatitis C virus (HCV) associated factors have been proposed to explain the variable outcomes in HCV recurrence. Recent evidence suggests that cytomegalovirus (CMV) infection not only is co-factor in progression of HCV recurrence but may precipitate allograft rejection. We investigated whether short-term CMV viremia influences HCV recurrence, the number and grade of acute rejection episodes, and the histological course of HCV recurrence during the first year after orthotopic liver transplantation (OLT) for HCV-related cirrhosis.

METHODS

A cohort of 39 patients transplanted for cirrhosis HCV-related was analyzed. Patients were evaluated twice weekly for CMV infection by a blood polymerase chain reaction (PCR) assay. Triple therapy with cyclosporine or tacrolimus, azathioprine and prednisolone was the initial immunosuppressive regimen. Preemptive treatment with ganciclovir was started when two consecutive PCRs for CMV were positive. Liver biopsies were performed on day 7 after OLT or when indicated. A 3-day IV 1 g methilprednisolone was given to patients with moderate or severe rejection. Ishak's score was used to grade inflammation and to stage fibrosis.

RESULTS

Neither CMV viremia nor CMV disease after OLT for HCV-related cirrhosis adversely influenced the incidence and grade of acute rejection episodes nor the histological outcome of post transplant HCV recurrence, during the first year after liver transplantation.

CONCLUSION

CMV viremia as detected by PCR does not affect the progression of HCV recurrence in liver grafts.

The clinical indications for plain radiography in acute knee trauma

OBJECTIVES

to assess the key symptoms and physical signs in the acutely injured knee that are significantly associated with fracture and utilise these to develop an algorithm for the use of radiography in acute knee trauma.

DESIGN

retrospective review of all acute knee injuries presenting to the accident and emergency unit at a District General Hospital over a 6-month period in 1998 (over 500 cases). After exclusions, a study group of 370 eligible adults was obtained. These patients were reviewed for the key symptoms and physical signs, and radiological evidence of fracture.

OUTCOME MEASURES

the X-ray films were interpreted by a consultant radiologist. Of those patients on whom radiographs were not performed, follow up was assessed by a review of any re-attendance to the A&E department.

RESULTS

there was a statistically significant correlation, using chi-square (Mantel-Haentzel) and linear regression analysis, between the presence of a fracture and each of the following variables: age, non-weightbearing in the department (p<0.05), haemarthrosis, point bony tenderness, effusion (p<0.001).

CONCLUSION

these key symptoms and physical signs may form the basis of an algorithm for examining knees radiologically, with acceptable positive and negative predictive values. (This is currently being tested prospectively).

The biological sciences in mental health nursing: stakeholders' perspectives

To date, relatively little attention has been paid to optimizing the development of education programmes to support safe and effective health care professionals. In particular, the wider stakeholders, particularly health service users, are rarely consulted on the knowledge base expected of practitioners. We report here on an evaluation, involving students, lecturers, nurses and service users, aimed at reviewing the bioscience component of the preregistration mental health nursing course. Students and lecturers agreed that the current common foundation course in bioscience was biased towards the adult branch students, and failed to meet the needs of mental health nurses. The mental health lecturers' solution to the 'bioscience problem' was to curtail the input. In contrast, service users described serious shortfalls in professionals' abilities to inform them of common side-effects of medication; these problems were attributable to inadequate educational preparation. The knowledge deficits identified could be rectified by making pharmacology an important part of the mental health education programme. However, for the curriculum to accommodate applied pharmacology, its supporting bioscience, and essential preparation in psychosocial interventions, some restructuring of the biological science programme for mental health nurses will be necessary. Our findings suggest that such restructuring should be informed by service users' views of their needs.

[A retinoid constituent of lipofuscin, A2-E, is a photosensitizer in human retinal pigment epithelial cells]

BACKGROUND

A fluorescent compound of lipofuscin, A2-E, has been shown to impair lysosomal function and to increase the intralysosomal pH of human retinal pigment epithelial (RPE) cells. This study addressed the phototoxic potential of A2-E on RPE cells.

METHODS

A2-E accumulation was confirmed by fluorescence microscopy and fluorescence-activated cell sorter analysis. Acridine orange staining allowed assessment of lysosomal integrity and intralysosomal pH. Phototoxic properties of A2-E were determined by exposing A2-E-free and A2-E-fed RPE cell cultures to short-wavelength visible light and assessing cell viability and lysosomal integrity.

RESULTS

Intralysosomal accumulation of A2-E was confirmed. Acridine orange staining showed that the A2-E was located in the lysosomal compartment and induced an elevation of intralysosomal pH. Exposure of A2-E fed cells to light resulted in a significant loss of cell viability by 72 h which was not observed in either RPE cells maintained in the dark or A2-E-free cultures exposed to light. Toxicity was associated with a loss of lysosomal integrity.

CONCLUSION

A2-E is detrimental to RPE cell function by a variety of mechanisms including inhibition of lysosomal degrading capacity, loss of membrane integrity, and phototoxicity. Such mechanisms could contribute to retinal aging and to retinal diseases associated with excessive lipofuscin accumulation.

A refined physical and transcriptional map of the SPG9 locus on 10q23.3-q24.2

Hereditary spastic paraplegia (HSP) is a genetically heterogeneous disorder characterised by progressive spasticity of the lower limbs. Beside 'pure' forms of HSP, 'complicated' forms are reported, where spasticity occurs associated with additional symptoms. We recently described an Italian family with a complicated dominant form of HSP (SPG9) and we mapped the gene responsible to 10q23.3-q24.2, in a 12cM interval between markers D10S564 and D10S603. The phenotypic manifestations in our family are reminiscent of those already described in a smaller British pedigree. We typed individuals from this British family using markers located in the SPG9 critical interval and haplotype reconstruction showed the disorder co-segregating with SPG9. To characterise the SPG9 region better, we constructed a contig of 22 YACs, assigned it to 18 polymorphic markers and positioned 54 ESTs. Furthermore, we searched for ESTs containing a trinucleotide repeat sequence, since anticipation of symptoms was reported in both families. Finally, analysis of a muscle biopsy specimen from one patient was normal, suggesting that, contrary to SPG7, mitochondrial disturbance could not be a primary feature of SPG9.

Long-term care must not be the ugly sister

There is a saying that: ‘If geriatrics is the Cinderella of services then longterm care is the ugly sister’. This sentiment accurately reflects the denigrated status of long-term care within the health and social services. Therefore, anything that seeks to raise the profile of work within such environments and to improve the quality of care given to the frailest and most vulnerable of older people is to be welcomed. This is the purpose of the recent report The Health and Care of Older People in Care Homes (Royal College of Physicians et al, 2000).

Phase 3 study comparing methotrexate and tacrolimus with methotrexate and cyclosporine for prophylaxis of acute graft-versus-host disease after marrow transplantation from unrelated donors

After the transplantation of unmodified marrow from human leukocyte antigen-matched unrelated donors receiving cyclosporine (CSP) and methotrexate (MTX), the incidence of acute graft-versus-host disease (GVHD) is greater than 75%. Tacrolimus is a macrolide compound that, in previous preclinical and clinical studies, was effective in combination with MTX for the prevention of acute GVHD. Between March 1995 and September 1996, 180 patients were randomized in a phase 3, open-label, multicenter study to determine whether tacrolimus combined with a short course of MTX (n = 90), more than CSP and a short course of MTX (n = 90), would reduce the incidence of acute GVHD after marrow transplantation from unrelated donors. There was a significant trend toward decreased severity of acute GVHD across all grades (P =.005). Based on the Kaplan-Meier estimate, the probability of grade II-IV acute GVHD in the tacrolimus group (56%) was significantly lower than in the CSP group (74%; P =.0002). Use of glucocorticoids for the management of GVHD was significantly lower with tacrolimus than with CSP (65% vs 81%, respectively; P =. 019). The number of patients requiring dialysis in the first 100 days was similar (tacrolimus, 9; CSP, 8). Overall and relapse-free survival rates for the tacrolimus and CSP arms at 2 years was 54% versus 50% (P =.46) and 47% versus 42% (P =.58), respectively. The combination of tacrolimus and MTX after unrelated donor marrow transplantation significantly decreased the risk for acute GVHD than did the combination of CSP and MTX, with no significant increase in toxicity, infections, or leukemia relapse.

Enterocolitis in children with developmental disorders

OBJECTIVE

Intestinal pathology, i.e., ileocolonic lymphoid nodular hyperplasia (LNH) and mucosal inflammation, has been described in children with developmental disorders. This study describes some of the endoscopic and pathological characteristics in a group of children with developmental disorders (affected children) that are associated with behavioral regression and bowel symptoms, and compares them with pediatric controls.

METHODS

Ileocolonoscopy and biopsy were performed on 60 affected children (median age 6 yr, range 3-16; 53 male). Developmental diagnoses were autism (50 patients), Asperger's syndrome (five), disintegrative disorder (two), attention deficit hyperactivity disorder (ADHD) (one), schizophrenia (one), and dyslexia (one). Severity of ileal LNH was graded (0-3) in both affected children and 37 developmentally normal controls (median age 11 yr, range 2-13 yr) who were investigated for possible inflammatory bowel disease (IBD). Tissue sections were reviewed by three pathologists and scored on a standard proforma. Data were compared with ileocolonic biopsies from 22 histologically normal children (controls) and 20 children with ulcerative colitis (UC), scored in an identical manner. Gut pathogens were sought routinely.

RESULTS

Ileal LNH was present in 54 of 58 (93%) affected children and in five of 35 (14.3%) controls (p < 0.001). Colonic LNH was present in 18 of 60 (30%) affected children and in two of 37 (5.4%) controls (p < 0.01). Histologically, reactive follicular hyperplasia was present in 46 of 52 (88.5%) ileal biopsies from affected children and in four of 14 (29%) with UC, but not in non-IBD controls (p < 0.01). Active ileitis was present in four of 51 (8%) affected children but not in controls. Chronic colitis was identified in 53 of 60 (88%) affected children compared with one of 22 (4.5%) controls and in 20 of 20 (100%) with UC. Scores of frequency and severity of inflammation were significantly greater in both affected children and those with UC, compared with controls (p < 0.001).

CONCLUSIONS

A new variant of inflammatory bowel disease is present in this group of children with developmental disorders.

Unique aspects of caring for dying children and their families

Pediatric hospice has become an important service for children and their families in the past decade. In this article we present unique aspects of StarShine, the hospice of Children's Hospital Medical Center in Cincinnati, Ohio. Length-of-service data demonstrate the need to find innovative ways of encouraging earlier referral to hospice. Several specialized aspects of care, such as long-term bereavement, pet visitation and social services for the family are presented. The initiation of a novel in-home pain management program is described. StarShine has not followed an adult hospice model, and as such, we discuss those unique aspects of dying pediatric patients and suggest specific solutions and interventions designed for children.