High-dose intrathecal diamorphine for analgesia after Caesarean section

Forty women undergoing elective Caesarean section under spinal anaesthesia using hyperbaric 0.5% bupivacaine were randomly allocated to receive either 0.5 mg or 1 mg intrathecal diamorphine. All women received diclofenac 100 mg at the end of surgery and morphine via a patient-controlled analgesia system. Oral analgesics were not used. Postoperative analgesia was more prolonged and more reliable in the 1-mg group. Mean time to first analgesia was 10.2 h in the 1-mg group and 6.9 h in the 0.5-mg group, and 45% in the 1-mg group used no morphine, compared with 10% in the 0.5-mg group. Mean morphine consumption over 24 h was 5.2 mg in the 1-mg group and 10.6 mg in the 0.5-mg group. Pain scores all tended to be lower in the 1-mg group but this was only significant at 4 h. There were no serious side-effects. Minor side-effects were common but well tolerated, and the incidence did not differ between the groups. If intrathecal diamorphine is used in combination with rectal diclofenac and without oral analgesia, then 1 mg provides superior analgesia to 0.5 mg without any worsening of the side-effects.

Safety of the Canadian blood supply in 1980-85: using a paediatric cohort for risk assessment of human immunodeficiency virus (HIV) infection

The risk of HIV from transfusions in Canada in the period 1980-85 was estimated, using the information from a transfused paediatric cohort. Children who were transfused between January 1980 and November 1985 at a tertiary care paediatric hospital were contacted by letter. With this notification, HIV testing for recipients was recommended. HIV testing histories were obtained. The number tested for HIV was estimated from the questionnaire responses and from data matching with the HIV-testing laboratory. Cases of HIV infection were identified through multiple sources. In this cohort, 11,028 children were transfused a mean of 21 units. Of the 10,220 living recipients, the estimated proportion tested for HIV was 86% to 91%. Thirty-one cases of HIV infection were identified, representing 0.28% of the cohort but 0.34% of those expected to have been tested. The estimated HIV incidence per 1,000 units transfused ranged from 0.028 [95% CI 0.0007, 0.155] in 1980 to 0.445 [95% CI 0.2592, 0.712] in 1985. This suggests that the risk of HIV from transfusions in Canada continued to rise until the implementation of HIV testing of donors in November 1985.

Compensating for our load of mutations: freezing the meltdown of small populations

We have investigated the reduction of fitness caused by the fixation of new deleterious mutations in small populations within the framework of Fisher's geometrical model of adaptation. In Fisher's model, a population evolves in an n-dimensional character space with an adaptive optimum at the origin. The model allows us to investigate compensatory mutations, which restore fitness losses incurred by other mutations, in a context-dependent manner. We have conducted a moment analysis of the model, supplemented by the numerical results of computer simulations. The mean reduction of fitness (i.e., expected load) scaled to one is approximately n/(n+2Ne), where Ne is the effective population size. The reciprocal relationship between the load and Ne implies that the fixation of deleterious mutations is unlikely to cause extinction when there is a broad scope for compensatory mutations, except in very small populations. Furthermore, the dependence of load on n implies that pleiotropy plays a large role in determining the extinction risk of small populations. Differences and similarities between our results and those of a previous study on the effects of Ne and n are explored. That the predictions of this model are qualitatively different from studies ignoring compensatory mutations implies that we must be cautious in predicting the evolutionary fate of small populations and that additional data on the nature of mutations is of critical importance.

Antinociceptive and anti-inflammatory properties of an adenosine kinase inhibitor and an adenosine deaminase inhibitor

Spinal administration of an adenosine kinase inhibitor, alone or in combination with an adenosine deaminase inhibitor, produces antinociception in inflammatory pain tests. In the present study, we examined the antinociceptive and anti-inflammatory effects produced by the peripheral (intraplantar) administration of 5'-amino-5'-deoxyadenosine (an adenosine kinase inhibitor), 2'-deoxycoformycin (an adenosine deaminase inhibitor), and combinations of both agents in the carrageenan-induced thermal hyperalgesia and paw oedema model in the rat. When injected in the ipsilateral paw immediately prior to carrageenan injection, both agents produced antinociception only at the highest dose (1 micromol), whereas a reduction in paw swelling was evident at a lower dose (300 nmol). Significant augmentation in both the antinociceptive and anti-inflammatory effects was seen when 5'-amino-5'-deoxyadenosine and 2'-deoxycoformycin were co-administered in equimolar doses at all dose levels. Both effects were mediated via activation of adenosine receptors, as indicated by blockade by an adenosine receptor antagonist. When administered into the contralateral paw, 1 micromol 5'-amino-5'-deoxyadenosine+1 micromol 2'-deoxycoformycin produced prominent antinociception, indicating a systemic drug activity. There was only a modest reduction in paw oedema in the carrageenan-injected (ipsilateral) paw, suggesting that much of this activity was locally mediated. Reversal of systemic effects on thermal thresholds by an intrathecal adenosine receptor antagonist implicates a spinal site of action in this instance. An ipsilateral administration of 1 micromol 5'-amino-5'-deoxyadenosine, but not 1 micromol 2'-deoxycoformycin, reduced carrageenan-induced c-Fos expression in the spinal dorsal horn, and this was further reduced by the peripheral co-injection of the two agents. These results provide evidence for a predominantly spinal antinociceptive effect and a predominantly peripheral anti-inflammatory effect produced by inhibitors of adenosine kinase and adenosine deaminase.

Eye injuries in patients with major trauma

BACKGROUND

A study was performed to determine the type and frequency of ocular injuries in patients with major trauma.

METHODS

All patients with ocular and adnexal injuries (n = 178) among 1,119 patients admitted with major trauma (Injury Severity Score >15) to the Royal Prince Alfred Hospital from July 1990 to December 1997 were analyzed.

RESULTS

Sixteen percent of the major trauma cohort had ocular or orbital trauma. Fifty-five percent of patients with injuries involving the face had ocular or orbital injuries. A range of ocular injuries was seen. Analysis of the major trauma cohort showed that motor vehicle drivers, orbital and base of skull fractures, eyelid lacerations, and superficial eye injuries were strongly associated with vision-threatening injury.

CONCLUSION

Patients with major trauma and facial injuries have a high risk of vision-threatening injury. Patients with orbital fractures, base of skull fracture, eyelid lacerations, and superficial eye injuries should be assessed by an ophthalmologist as part of the early management of their trauma to determine whether an ocular injury is present.

Nutricel as an additive solution for neonatal transfusion

Red cell concentrates stored in additive solutions have limitations for use in the pediatric population. Our survey of 10 pediatric institutions found that Nutricel supernatant was often removed prior to infusion. Examination of packed red cells showed a potassium concentration in excess of 15 mmol/l by day 7 in AS-3 and 40 mmol/l by day 35. Comparison with cells stored in CP2D and CPDA1 showed that the total mass of potassium was highest in AS-3 (5.6 mmol/l) as was the phosphate. The total mass of citrate and glucose was considerably increased in the AS-3 system at 1.73 mmoles and 3.23 mmoles. All had a pH less than 6.6 at day 35. The high concentration of potassium in AS-3 raises concern for the potential for hyperkalemic dysrhythmias during massive transfusion while the citrate load has clinical implications for divalent cation homeostasis during rapid infusion or exchange; the glucose may induce hyperglycemic sequelae.

The economic impact of Staphylococcus aureus infection in New York City hospitals

We modeled estimates of the incidence, deaths, and direct medical costs of Staphylococcus aureus infections in hospitalized patients in the New York City metropolitan area in 1995 by using hospital discharge data collected by the New York State Department of Health and standard sources for the costs of health care. We also examined the relative impact of methicillin-resistant versus -sensitive strains of S. aureus and of community-acquired versus nosocomial infections. S. aureus-associated hospitalizations resulted in approximately twice the length of stay, deaths, and medical costs of typical hospitalizations; methicillin-resistant and -sensitive infections had similar direct medical costs, but resistant infections caused more deaths (21% versus 8%). Community-acquired and nosocomial infections had similar death rates, but community-acquired infections appeared to have increased direct medical costs per patient ($35,300 versus $28,800). The results of our study indicate that reducing the incidence of methicillin-resistant and -sensitive nosocomial infections would reduce the societal costs of S. aureus infection.

Genetic characterization and heterologous expression of brochocin-C, an antibotulinal, two-peptide bacteriocin produced by Brochothrix campestris ATCC 43754

Brochocin-C, produced by Brochothrix campestris ATCC 43754, is active against many strains of the closely related meat spoilage organism Brochothrix thermosphacta and a wide range of other gram-positive bacteria, including spores of Clostridium botulinum. Purification of the active compound and genetic characterization of brochocin-C revealed that it is a chromosomally encoded, two-peptide nonlantibiotic bacteriocin. Both peptides of brochocin-C are ribosomally synthesized as prepeptides that are typical of class II bacteriocins. They are cleaved following Gly-Gly cleavage sites to yield the mature peptides, BrcA and BrcB, containing 59 and 43 amino acids, respectively. Fusion of the nucleotides encoding the signal peptide of the bacteriocin divergicin A in front of the structural genes for either BrcA or BrcB allowed independent expression of each component by the general protein secretion pathway. This revealed the two-component nature of brochocin-C and the necessity for both peptides for activity. A 53-amino-acid peptide encoded downstream of brcB functions as the immunity protein (BrcI) for brochocin-C. In addition, the cloned chromosomal fragment revealed open reading frames downstream of brcI, designated brcT and brcD, that encode proteins with homology to ATP-binding cassette translocator and accessory proteins, respectively, involved in the secretion of Gly-Gly-type bacteriocins.

Is bone marrow aspiration needed in acute childhood idiopathic thrombocytopenic purpura to rule out leukemia?

OBJECTIVE

To assess the prevalence of leukemia in a series of bone marrow aspiration (BMA) samples collected to confirm provisional diagnoses of acute idiopathic thrombocytopenic purpura (ITP) in children.

DESIGN

A retrospective cohort.

SETTING

All BMA reports at The Hospital for Sick Children, Toronto, Ontario (a tertiary care pediatric hospital), from January 1, 1984, to May 31, 1996, were reviewed.

PATIENTS

Included were BMAs performed to confirm provisional diagnoses of ITP in children (6 months to 18 years of age) with "typical" contemporaneous hematologic features of ITP (platelet count, < or =50 x 10(9)/L; hemoglobin level, > or =100 g/L [6-12 months of age] or > or =110 g/L [> 1 year of age]; white blood cell count, > or =5 x 10(9)/L [6 months to 6 years of age] or > or =4 x 10(9)/L [> 6 years of age]; and neutrophil count, > or =1.5 x 10(9)/L [6 months to 6 years of age] or > or =2 x 10(9)/L [> 6 years of age]). Children with chronic ITP, thrombocytopenia-related chronic conditions, or leukemic blasts on peripheral smears were excluded.

MAIN OUTCOME MEASURE

The finding of leukemia in the BMA report was chosen a priori as the primary outcome for the yield of BMA.

RESULTS

Four hundred eighty-four BMAs were performed to confirm provisional diagnoses of acute childhood ITP. No diagnoses of leukemia were revealed in the 332 children with typical hematologic features of ITP. The risk of missing the diagnosis of leukemia in this setting is less than 1%.

CONCLUSIONS

The yield of BMA for leukemia in this setting is low. Routine BMA is not necessary for children with typical acute ITP.

Recurrent scleritis in lepromatous leprosy

BACKGROUND

Recurrent immune-mediated scleritis after adequate treatment of leprosy is not well documented in the literature. We describe an Australian resident with unilateral intra-ocular lepromatous leprosy who had persistent non-infectious scleritis.

METHODS

A man of Anglo-Indian ancestry initially presented with lepromatous leprosy and unilateral ocular involvement. The affected eye had an interstitial keratitis and a granulomatous anterior uveitis that responded to antileprotics and anti-inflammatory agents. Despite systemic cure with triple antileprotic therapy, he developed recurrent scleritis that required multiple scleral patch grafts for scleral thinning and, subsequently, an enucleation. Histology failed to demonstrate persistent infection, rather a chronic non-granulomatous scleritis, which was probably immune mediated.

RESULTS/CONCLUSIONS

This case demonstrates an ocular complication of leprosy that is infrequently reported. Patients with ocular involvement by leprosy are at risk of developing recurrent scleritis despite systemic cure with antileprotics.

Antinociception by adenosine analogs and inhibitors of adenosine metabolism in an inflammatory thermal hyperalgesia model in the rat

The present study examined the spinal antinociceptive effects of adenosine analogs and inhibitors of adenosine kinase and adenosine deaminase in the carrageenan-induced thermal hyperalgesia model in the rat. The possible enhancement of the antinociceptive effects of adenosine kinase inhibitors by an adenosine deaminase inhibitor also was investigated. Unilateral hindpaw inflammation was induced by an intraplantar injection of lambda carrageenan (2 mg/100 microl), which consistently produced significant paw swelling and thermal hyperalgesia. Drugs were administered intrathecally, either by acute percutaneous lumbar puncture (individual agents and combinations) or via an intrathecal catheter surgically implanted 7-10 days prior to drug testing (antagonist experiments). N6-cyclohexyladenosine (CHA; adenosine A1 receptor agonist; 0.01-1 nmol), 2-[p-(2-carboxyethyl)phenylethylamino]-5'-N-ethylcarboxamidoadenos ine (CGS21680; adenosine A2A receptor agonist; 0.1-10 nmol), 5'-amino-5'-deoxyadenosine (NH2dAdo; adenosine kinase inhibitor: 10-300 nmol), and 5-iodotubercidin (ITU; adenosine kinase inhibitor; 0.1-100 nmol) produced, to varying extents, dose-dependent antinociception. No analgesia was seen following injection of 2'-deoxycoformycin (dCF; an adenosine deaminase inhibitor; 100-300 nmol). Reversal of drug effects by caffeine (non-selective adenosine A1/A2 receptor antagonist; 515 nmol) confirmed the involvement of the adenosine receptor, while antagonism by 8-cyclopentyl-1,3-dimethylxanthine (CPT; adenosine A1 receptor antagonist; 242 nmol), but not 3,7-dimethyl-1-propargylxanthine (DMPX; adenosine A2A receptor antagonist; 242 nmol), evidenced an adenosine A1 receptor mediated spinal antinociception by NH2dAdo. dCF (100 nmol), which was inactive by itself, enhanced the effects of 10 nmol and 30 nmol NH2dAdo. Enhancement of the antinociceptive effect of ITU by dCF was less pronounced. None of the antinociceptive drug regimens had any effect on paw swelling. These results demonstrate that both directly and indirectly acting adenosine agents, when administered spinally, produce antinociception through activation of spinal adenosine A1 receptors in an inflammatory model of thermal hyperalgesia. The spinal antinociceptive effects of selected adenosine kinase inhibitors can be significantly augmented when administered simultaneously with an adenosine deaminase inhibitor.

Primary basal cell carcinoma of the caruncle

Basal cell carcinomas (BCCs) of the caruncle are rare. We report a case of a primary BCC of the caruncle in a 74-year-old man who was seen with a medial interpalpebral lesion. He had a history of sun exposure and multiple malignant neoplasms of the skin. The lesion was excised and histological examination showed a BCC of the caruncle. The clinical history, examination findings, and histological features are given.

Regional cancer cytogenetics: a report on 1,143 diagnostic cases

The results of studies from a regional cancer cytogenetics diagnostic service are reported. In a 10-year period, 1,143 marrow samples from patients with newly diagnosed leukemia and myelodysplastic syndrome were referred. Successful studies were completed on 992 cases (87%). Among all referred cases, the rates of detection of cytogenetically abnormal clones were 95% for chronic myelogenous leukemia (CML), 54% for acute lymphoblastic leukemia (ALL), 51% for acute myeloid leukemia (ANLL), and 43% for myelodysplastic syndrome (MDS). Of 169 cases of CML studied, 90.5% bore the standard Philadelphia chromosome (Ph), 3.55% had an unusual Ph, and 5.33% were Ph-negative. Among the 59 cases of cytogenetically abnormal MDS, common abnormalities observed were trisomy 8 and changes resulting in loss of material from the long arm of chromosomes 5 and 7, and 20q-. Of the 168 abnormal ANLL, there was a strikingly non-random pattern of aneuploidy, with monosomy 7 and trisomy 8 predominating. Common structural changes observed were changes resulting in loss of material from the long arm of chromosomes 5 and 7, trisomy 8, rearrangements of 11q23, t(15;17), t(8;21), rearrangements of 12q13 and 3q, inversion 16, trisomy 11, Ph, trisomy 21, t(6;9) and t(1;22). The differences between adult and pediatric findings were minor, with the exception of chromosome 5 abnormalities, which were common among adults with ANLL but rare in the pediatric cases. There were 273 ALLs with abnormal cytogenetic findings. There was preferential gain of chromosomes 21, X, 14, 6, 4, 18, 17, and 10 (in decreasing order of frequency) in leukemic clones. Of the 193 ALLs with structural changes, many fell into-well-defined categories with established correlations to FAB subtypes. Common changes in ALL were rearrangements of 9p, 12p, 6q, TCR loci, 11q23, Ig loci, and 8q24, and duplication of 1q, Ph, i(17q), t(1;19), i(9q) and dic(9;12). The detailed documentation of the cytogenetic findings in this relatively large, single-institution study will likely facilitate the further characterization of rare, primary cytogenetic changes associated with leukemias and MDS. From a managed health care perspective, regional cancer cytogenetic services may be cost-effective alternatives to single-institution laboratories.

A simple snare for transscleral fixation of dislocated intraocular lenses

PURPOSE

The construction and use of a surgical snare in retrieving and securing posterior chamber intraocular lenses is described.

METHODS

The snare consists of a 10-O polypropylene suture threaded into a 25-gauge retrobulbar needle. This is used after a pars plana vitrectomy to retrieve the dislocated intraocular lens. The needle attached to the polypropylene suture is used to secure the lens haptic 1.5 mm behind the limbus. Two snares are used to secure the two lens haptics.

CONCLUSIONS

The snare is easy to make with readily available materials. The use of this snare involves less intraocular and extraocular manipulations than other described methods.

Acquired von Willebrand factor deficiency during high-dose infusion of recombinant factor VIII

Constant infusion of factor VIII (FVIII) into patients with haemophilia A after major surgery has been recommended as optimal treatment to avoid peaks and valleys in the circulating levels of FVIII and to allow the use of much lower doses of FVIII than are historically required. One of our young patients with severe (< 0.01 U/ml FVIII) haemophilia suffered a subdural haematoma for which he received treatment with 815190 recombinant FVIII (rFVIII) units over a period of 52d. 2 weeks after admission, because of low FVIII levels and the presence of FVIII inhibitors, the infusion rate was increased to > 100 U/kg/h for 14d. During this time the FVIII level fluctuated between 0.6 and 4.2 U/ml. For some period it was not possible to detect ristocetin co-factor activity in this patient's plasma and the von Willebrand factor (VWF) level and VWF multimer pattern resembled those of a patient with von Willebrand's disease. Subsequently, when the rFVIII dose was increased 2-fold, this was not reflected by the plasma level of FVIII although antibodies were not detected. The data suggest that the prolonged infusion of very high levels of rFVIII which is deficient in von Willebrand factor can result in depletion of VWF from existing stores, producing a laboratory picture which is consistent with the diagnosis of von Willebrand's disease. Further, in the absence of complexing with VWF, FVIII appears to be cleared from the circulation at an increased rate. This is expensive and potentially compromising. Therefore, when administering very high doses of FVIII concentrates devoid of VWF for prolonged periods of time, ristocetin cofactor and VWF levels should be monitored.

Antinociception by adenosine analogs and an adenosine kinase inhibitor: dependence on formalin concentration

Spinal administration of adenosine analogs and an adenosine kinase inhibitor produces antinociception in thermal threshold tests. In the present study, we determined the effects of N6-cyclohexyladenosine (adenosine A1 receptor selective), 2-[p-(2-carboxyethyl)phenylethylamino]-5'-N-ethyl-carboxamidoadeno sine (CGS-21680) (adenosine A2A receptor selective), and 5'-N-ethylcarboxamidoadenosine (NECA) (non-selective), on formalin induced nociceptive responses (flinching/lifting and licking/biting) using two concentrations of formalin (2% and 5%). We also examined the antinociceptive effects of 5'-amino-5'-deoxyadenosine, an adenosine kinase inhibitor, and deoxycoformycin, an adenosine deaminase inhibitor, under these conditions. Adenosine A1 receptor agonists, but not the A2A selective agent, produced significant antinociception, as did 5'-amino-5'-deoxyadenosine, but not deoxycoformycin. The extent of antinociception produced was greater with the lower stimulus intensity. The effects of NECA and 5'-amino-5'-deoxyadenosine were inhibited by caffeine, indicating the involvement of cell surface adenosine receptors in their actions. We conclude (a) that the adenosine A1, but not the A2A, receptor is involved in spinally mediated antinociception, (b) that adenosine kinase is more important than adenosine deaminase in regulating endogenous adenosine levels in the spinal cord, and (c) that stimulus intensity is an important determinant of the efficacy of purines in the spinal cord.

Refractoriness to platelet transfusions in children with acute leukemia

PURPOSE

We evaluated the incidence of clinically significant refractoriness to platelet transfusions in children with acute leukemia.

PATIENTS AND METHODS

We reviewed the complete transfusion records up to July 1993 of all 213 patients diagnosed with acute leukemia at our institution over the 4-year period 1987 to 1990. The transfusion protocol called for all patients requiring transfusion of red cell and/or platelet concentrates to initially receive components that were not leukocyte reduced. Patients suspected clinically to be refractory to platelets were tested for anti-human leukocyte antigen (HLA) antibodies and those that tested positive were switched to HLA-matched platelets.

RESULTS

Of 184 patients diagnosed with acute lymphoblastic leukemia (ALL), 133 (72%) required platelet support, whereas all 29 patients with acute myeloid leukemia (AML) were transfused with platelets. The incidence of clinically suspected refractoriness to non-leukocyte-reduced platelets, which was confirmed by a positive test for anti-HLA antibodies and which resulted in a switch to HLA-matched platelets, was nine of 29 (31%) for patients with AML but only three of 133 (2.3%) for patients with ALL.

CONCLUSIONS

The results of this study indicate that clinically significant platelet refractoriness requiring transfusion of HLA-matched platelets occurs infrequently in childhood ALL. For this group of patients, use of leukocyte-depleted cellular components for the purpose of preventing platelet refractoriness cannot be justified. This approach may be appropriate for children with AML.

Patterns of visual loss associated with pituitary macroadenomas

PURPOSE

To describe the patterns of visual loss associated with pituitary macroadenomas compressing the anterior visual pathway.

METHOD

A prospective survey of 29 patients with pituitary macroadenomas who presented to the neurosurgical unit at St Vincent's Hospital, Melbourne. Selected patients had histologically verified pituitary macroadenomas, and visual defects (acuity, colour and/or field loss) consistent with anterior visual pathway compression.

RESULTS

All patients had visual field defects detected on perimetry, and the majority were asymmetrical. Bitemporal defects were most common but field defects ranged from monocular defects to generalised constriction. Four patients (13.8%) did not report visual symptoms, and of those who had symptoms, blurred vision was the most common complaint. Ninety-six per cent of eyes had field loss, 56% had decreased colour vision, 46% had decreased acuity, 31% had optic disc pallor, and 2% had an ophthalmoplegia.

CONCLUSIONS

Patients with visual pathway compression by pituitary macroadenomas may be asymptomatic despite having field defects. Perimetry is the most sensitive method of identifying compression, followed by colour vision, visual acuity, then the presence of optic atrophy. Automated static threshold perimetry appears to show early field defects better than manual kinetic perimetry. All patients with pituitary macroadenomas should have thorough ophthalmological examinations, including perimetry to document visual deficits secondary to compression.

Transient leukemia followed by megakaryoblastic leukemia in a child with mosaic Down syndrome

A case is presented of a child with mosaic Down syndrome, who presented at birth with a transient leukemia and later progressed to megakaryoblastic leukemia. Evidence is presented that both leukemias were of megakaryoblastic lineage and evolved from a trisomic hematopoietic precursor. This case is unique in the poor course of the initial transient neonatal leukemia with improvement following chemotherapy. It also highlights the form of leukemia and associated myelodysplasia that occurs in children with Down syndrome. This form of leukemia and transient leukemia are interrelated and are unique to children with Down syndrome.

Identification of at-risk drinkers in an orthopaedic inpatient population

The prevalence of hazardous drinking of alcohol in orthopaedic inpatients and its impact on patient management was determined. A prospective survey was performed on acute and arranged admissions in the orthopaedic wards at St Vincent's Hospital, Melbourne, over a 3 month period. At-risk drinking was measured by the AUDIT questionnaire, a score of eight or more suggesting hazardous drinking and a score of 20 or more suggesting dependence. A separate questionnaire recorded relevant details of the admission, complications during hospital stay, degree of difficulty nursing the patient and any past history of alcohol problems. Thirty-four (36%) of 94 patients were drinking at hazardous levels. Of these, 62% gave no prior history of problems with alcohol. Thirty-four per cent of 53 acute admissions and 39% of 41 arranged admissions were harmful drinkers suggesting that trauma may not be the only contribution to problem drinking in the orthopaedic setting. Hazardous drinking occurred in both male and female groups aged less than 55 years and in males greater than 55 years. Hazardous drinking was associated with more inpatient complications (chi 2 = 6.6, d.f. = 1, P = 0.01) and greater nursing difficulty (chi 2 = 5.5, d.f. = 1, P = 0.02). A third of the patients in the orthopaedic wards drink alcohol at hazardous levels, whether they are acute or arranged admissions. Hazardous drinking is associated with more complications and greater difficulty in nursing patients.

Nonimaging light concentration using total internal reflection films

We present a method of fabricating nonimaging light concentrators from total internal reflection film. A prototype has been made and tested and found to operate in agreement with predictions of ray-tracing codes. The performance of the prototype is comparable with that of concentrators made from specular reflecting materials.

Leukemia in Down syndrome: a review

The incidence of leukemia is higher in children with Down syndrome (DS) than in normals. In approximately 50% of cases the type of leukemia is acute megakaryoblastic leukemia (AMKL) and it occurs during the first 4 years of life. The leukemic cell also has features of erythroid progenitors and therefore appears to be a precursor cell with biphenotypic properties. In addition, newborns with DS frequently develop transient leukemia (TL), which is characterized by the presence of megakaryoblasts in the blood which disappear during the first 1-3 months of life. The incidence of this disorder is unknown although preliminary studies suggest that megakaryoblasts may be found frequently in the blood of DS newborns. TL does not occur in normal newborn infants. Although TL disappears spontaneously, many of these children will develop AMKL at 1-4 years of age. Recent surveys suggest that 20-30% of newborns with TL will develop AMKL. Preliminary evidence suggests that TL is a clonal proliferation, can be fatal, and may occur in a specific subgroup of DS children. The observations in this report are drawn from our own experience, reports in the literature, and data accumulated in the Canadian Down Syndrome Leukemia Registry.

Gas gangrene: an unusual cause of graft failure in an orthotopic pediatric liver transplant

Gas gangrene of the liver is a very unusual cause of graft failure, and gas gangrene caused by Enterobacter cloacae is also exceedingly rare. Although Clostridial infection could not be excluded in this case, the literature and our case show that Enterobacter cloacae can be present in gas gangrene tissue whether or not it is the only infecting organism.