Surveillance for waterborne-disease outbreaks--United States, 1997-1998

PROBLEM/CONDITION

Since 1971, CDC and the U.S. Environmental Protection Agency (EPA) have maintained a collaborative surveillance system for collecting and periodically reporting data relating to occurrences and causes of waterborne-disease outbreaks (WBDOs).

REPORTING PERIOD COVERED

This summary includes data from January 1997 through December 1998 and a previously unreported outbreak in 1996.

DESCRIPTION OF THE SYSTEM

The surveillance system includes data regarding outbreaks associated with drinking water and recreational water. State, territorial, and local public health departments are primarily responsible for detecting and investigating WBDOs and voluntarily reporting them to CDC on a standard form.

RESULTS

During 1997-1998, a total of 13 states reported 17 outbreaks associated with drinking water. These outbreaks caused an estimated 2,038 persons to become ill. No deaths were reported. The microbe or chemical that caused the outbreak was identified for 12 (70.6%) of the 17 outbreaks; 15 (88.2%) were linked to groundwater sources. Thirty-two outbreaks from 18 states were attributed to recreational water exposure and affected an estimated 2,128 persons. Eighteen (56.3%) of the 32 were outbreaks of gastroenteritis, and 4 (12.5%) were single cases of primary amebic meningoencephalitis caused by Naegleria fowleri, all of which were fatal. The etiologic agent was identified for 29 (90.6%) of the 32 outbreaks, with one death associated with an Escherichia coli O157:H7 outbreak. Ten (55.6%) of the 18 gastroenteritis outbreaks were associated with treated pools or ornamental fountains. Of the eight outbreaks of dermatitis, seven (87.5%) were associated with hot tubs, pools, or springs.

INTERPRETATION

Drinking water outbreaks associated with surface water decreased from 31.8% during 1995-1996 to 11.8% during 1997-1998. This reduction could be caused by efforts by the drinking water industry (e.g., Partnership for Safe Water), efforts by public health officials to improve drinking water quality, and improved water treatment after the implementation of EPA's Surface Water Treatment Rule. In contrast, the proportion of outbreaks associated with systems supplied by a groundwater source increased from 59.1% (i.e., 13) during 1995-1996 to 88.2% (i.e., 15) during 1997-1998. Outbreaks caused by parasites increased for both drinking and recreational water. All outbreaks of gastroenteritis attributed to parasites in recreational water were caused by Cryptosporidium, 90% occurred in treated water venues (e.g., swimming pools and decorative fountains), and fecal accidents were usually suspected. The data in this surveillance summary probably underestimate the true incidence of WBDOs because not all WBDOs are recognized, investigated, and reported to CDC or EPA.

ACTIONS TAKEN

To estimate the national prevalence of waterborne disease associated with drinking water, CDC and EPA are conducting a series of epidemiologic studies to better quantify the level of waterborne disease associated with drinking water in nonoutbreak conditions. The Information Collection Rule implemented by EPA in collaboration with the drinking water industry helped quantifythe level of pathogens in surface water. Efforts by CDC to address recreational water outbreaks have included meetings with the recreational water industry, focus groups to educate parents on prevention of waterborne disease transmission in recreational water settings, and publications with guidelines for parents and pool operators.

Proposal of a four-dimensional model of social response

Descriptive models of social response attempt to identify the conceptual dimensions necessary to define and distinguish various types of influence. Building on previous approaches, the authors propose a new response model and demonstrate that a minimum of 4 dimensions is necessary to adequately provide for such influence phenomena as conformity, minority influence, compliance, contagion, independence, and anticonformity in a single model. In addition, the proposed model suggests 5 potential types of response that have not been previously identified. These new types suggest directions for future research and theoretical development. Selected empirical evidence is reviewed in support of the validity and integrative power of the proposed model.

Allergic sensitization and clinical reactions to latex, food and pollen in adult patients

BACKGROUND

Many latex-allergic patients are sensitized to one or more foods. Patients allergic to tree and/or grass pollens are also often sensitized to plant-derived foods. Atopy, defined in most studies as sensitivity to an aeroallergen, is a risk factor for latex allergy. The relative importance of pollen sensitivity, a sign of atopy, as a risk factor for food allergy in latex-allergic patients has not, however, been examined.

OBJECTIVE

To investigate the relationship between pollen sensitivity and sensitivity to food in latex-allergic patients.

METHODS

Forty-four latex-allergic patients (Groups 1 and 2), 24 of whom were also allergic to tree and/or grass pollen (Group 1) and 25 pollinosis patients who were not allergic to latex (Group 3) were studied. We obtained a history of reactions to food and skin tested them with 12 fresh-frozen fruits.

RESULTS

All 12 foods induced a skin test reaction in at least one patient in each of the three Groups. There were, however, twice as many positive skin test reactions to food in patients with pollinosis, whether or not they were allergic to latex, as there were in patients allergic to latex but not to pollen. Latex-allergic patients were most likely to have a positive skin test and a history of a reaction to avocado or banana whereas patients with pollinosis only were most likely to have a positive skin test and a history of a reaction to apple, peach or celery.

CONCLUSIONS

These results suggest that concomitant allergy to pollen is an important risk factor in determining which plant-derived foods sensitize latex-allergic patients.

Genetic variation in Pneumocystis carinii isolates from different geographic regions: implications for transmission

To study transmission patterns of Pneumocystis carinii pneumonia (PCP) in persons with AIDS, we evaluated P. carinii isolates from patients in five U.S. cities for variation at two independent genetic loci, the mitochondrial large subunit rRNA and dihydropteroate synthase. Fourteen unique multilocus genotypes were observed in 191 isolates that were examined at both loci. Mixed infections, accounting for 17.8% of cases, were associated with primary PCP. Genotype frequency distribution patterns varied by patients' place of diagnosis but not by place of birth. Genetic variation at the two loci suggests three probable characteristics of transmission: that most cases of PCP do not result from infections acquired early in life, that infections are actively acquired from a relatively common source (humans or the environment), and that humans, while not necessarily involved in direct infection of other humans, are nevertheless important in the transmission cycle of P. carinii f. sp. hominis.

Validation of a flow cytometric assay detecting in vitro basophil activation for the diagnosis of muscle relaxant allergy

BACKGROUND

Anaphylactic reactions during anesthesia are mainly the result of muscle-relaxant (MR) drugs. Skin tests, serologic detection of specific IgE, and in vitro leukocyte histamine release are used to investigate MR allergy.

OBJECTIVE

We describe a new assay that is based on the detection by flow cytometry of the altered expression of plasma membrane molecules of MR-activated basophils.

METHODS

For this assay, which we have named the BASIC assay, basophils are incubated in vitro with MR, after which they are fixed and then triple labeled with fluorescein-conjugated anti-CD63, tandem dye R-phycoerythrin-cyanin 5.1 conjugated anti-CD45, and R-phycoerythrin conjugated anti-IgE. The resulting B asophils' A ltered S urface I mmunofluorescence is detected by flow C ytometry (BASIC).

RESULTS

Forty-one patients who had an allergic reaction during general anesthesia and 23 control subjects without such a history were studied. All included subjects' basophils were tested in the BASIC assay with at least 4 MR: suxamethonium, gallamine, vecuronium, and pancuronium. After reaction of the basophils of the MR-allergic patients with MRs, increased surface expression of CD63 and CD45 and decreased expression of IgE were detected. Increased expression of CD63 was observed most frequently and it was stronger than the alteration of the 2 other markers. Cross-reactivity between MRs commonly occurred. MRs diluted 10(-1) activate the basophils of the control subjects, suggesting that at relatively high concentrations MRs are also nonspecific basophil activators.

CONCLUSION

In the diagnosis of MR allergy, the BASIC assay has a good specificity but a low sensitivity, and it correlates strongly with skin test results. It is currently appraised for the diagnosis of anaphylactic reaction induced by other classes of drugs.

Transrectal ultrasound-guided intraprostatic injection of absolute ethanol with and without carmustine: a feasibility study in the canine model

OBJECTIVES

To develop a reliable intraprostatic injection technique and to define the local and systemic toxicity of intraprostatic injection of dehydrated ethanol with and without carmustine.

METHODS

Twenty-three random-source male canines were divided into a control group (n = 3), a dehydrated ethanol-alone group (group 1, n = 10), and a dehydrated ethanol-plus-carmustine group (group 2, n = 10). A reliable intraprostatic injection technique was developed with the control animals. The optimal volume of dehydrated ethanol for intraprostatic injection and the local tissue effects of dehydrated ethanol injection were defined with group 1. The local tissue effects of escalating doses of carmustine were defined with group 2. All animals were injected under general anesthesia using transrectal ultrasound (TRUS) guidance. Fourteen days after injection, a repeated TRUS of the prostate was done, the animals were killed, and the bladder, prostate, and periprostatic tissues were excised for pathologic examination.

RESULTS

Sonographic changes in the prostate 2 weeks after injection were present in all group 1 and 2 animals. All prostates had varying amounts of hemorrhagic and coagulative necrosis, which correlated with the TRUS findings. There were no differentiating pathologic features between group 1 and group 2 specimens. The relative amount of necrosis varied with the doses of dehydrated ethanol and carmustine injected, but was not predictable on the basis of the doses administered. Subclinical prostatic microabscesses were identified in 6 of 10 group 1 animals and 4 of 10 group 2 animals. Only group 2 animals had alterations in their blood chemistry results, all of which were self-limited. Two had white blood cell nadirs of less than 2000 5 days after injection. No animals developed incontinence, and there were no rectal injuries.

CONCLUSIONS

Intraprostatic dehydrated ethanol and carmustine injections were readily controllable under TRUS guidance and resulted in hemorrhagic and coagulative necrosis of prostatic tissue with minimal associated morbidity and no incontinence in the dog model. Hematologic changes observed in the animals that received carmustine were self-limiting.

Surveillance for waterborne-disease outbreaks--United States, 1995-1996

PROBLEM/CONDITION

Since 1971, CDC and the U.S. Environmental Protection Agency have maintained a collaborative surveillance system for collecting and periodically reporting data that relate to occurrences and causes of waterborne-disease outbreaks (WBDOs).

REPORTING PERIOD COVERED

This summary includes data for January 1995 through December 1996 and previously unreported outbreaks in 1994.

DESCRIPTION OF THE SYSTEM

The surveillance system includes data about outbreaks associated with drinking water and recreational water. State, territorial, and local public health departments are primarily responsible for detecting and investigating WBDOs and for voluntarily reporting them to CDC on a standard form.

RESULTS

For the period 1995-1996, 13 states reported a total of 22 outbreaks associated with drinking water. These outbreaks caused an estimated total of 2,567 persons to become ill. No deaths were reported. The microbe or chemical that caused the outbreak was identified for 14 (63.6%) of the 22 outbreaks. Giardia lamblia and Shigella sonnei each caused two (9.1%) of the 22 outbreaks; Escherichia coli O157:H7, Plesiomonas shigelloides, and a small round structured virus were implicated for one outbreak (4.5%) each. One of the two outbreaks of giardiasis involved the largest number of cases, with an estimated 1,449 ill persons. Seven outbreaks (31.8% of 22) of chemical poisoning, which involved a total of 90 persons, were reported. Copper and nitrite were associated with two outbreaks (9.1% of 22) each and sodium hydroxide, chlorine, and concentrated liquid soap with one outbreak (4.5%) each. Eleven (50.0%) of the 22 outbreaks were linked to well water, eight in noncommunity and three in community systems. Only three of the 10 outbreaks associated with community water systems were caused by problems at water treatment plants; the other seven resulted from problems in the water distribution systems and plumbing of individual facilities (e.g., a restaurant). Six of the seven outbreaks were associated with chemical contamination of the drinking water; the seventh outbreak was attributed to a small round structured virus. Four of the seven outbreaks occurred because of backflow or backsiphonage through a cross-connection, and two occurred because of high levels of copper that leached into water after the installation of new plumbing. For three of the four outbreaks caused by contamination from a cross-connection, an improperly installed vacuum breaker or a faulty backflow prevention device was identified; no protection against backsiphonage was found for the fourth outbreak. Thirty-seven outbreaks from 17 states were attributed to recreational water exposure and affected an estimated 9,129 persons, including 8,449 persons in two large outbreaks of cryptosporidiosis. Twenty-two (59.5%) of these 37 were outbreaks of gastroenteritis; nine (24.3%) were outbreaks of dermatitis; and six (16.2%) were single cases of primary amebic meningoencephalitis caused by Naegleria fowleri, all of which were fatal. The etiologic agent was identified for 33 (89.2%) of the 37 outbreaks. Six (27.3%) of the 22 outbreaks of gastroenteritis were caused by Cryptosporidium parvum and six (27.3%) by E. coli O157:H7. All of the latter were associated with unchlorinated water (i.e., in lakes) or inadequately chlorinated water (i.e., in a pool). Thirteen (59.1%) of these 22 outbreaks were associated with lake water, eight (36.4%) with swimming or wading pools, and one(4.5%) with a hot spring. Of the nine outbreaks of dermatitis, seven (77.8%) were outbreaks of Pseudomonas dermatitis associated with hot tubs, and two (22.2%) were lake-associated outbreaks of swimmer's itch caused by Schistosoma species.

INTERPRETATION

WBDOs caused by E. coli O157:H7 were reported more frequently than in previous years and were associated primarily with recreational lake water. This finding suggests the need for better monitoring of water quality and identification of sources of

Bleomycin associated pulmonary toxicity: is perioperative oxygen restriction necessary?

PURPOSE

We delineate predictive factors of pulmonary morbidity in patients who receive combination chemotherapy with bleomycin and undergo surgical resection of residual disease, and establish updated guidelines for perioperative management.

MATERIALS AND METHODS

A total of 77 patients with high volume stage II to IV nonseminomatous germ cell tumors underwent 97 major surgical procedures a mean of 6.4 months following high dose combination chemotherapy, including bleomycin (mean 437.5 units per 8.2 courses), between 1988 and 1995 at the University of Texas M. D. Anderson Cancer Center. The importance of preoperative pulmonary status, anesthesia time, fraction of inspired oxygen, fluid balance, bleomycin dose, number of acute toxicity episodes, oxygen saturation problems and pulmonary symptoms was examined. Cases were divided into groups according to whether there were postoperative oxygen saturation problems (19) or not (58).

RESULTS

There were no significant differences in age, weight, bleomycin dose, number of acute toxicity episodes, cardiac ejection fraction or preoperative pulmonary symptoms between the 2 groups. Restrictive spirometry patterns were seen in 26 of 74 patients (35%), only 9 of whom had postoperative oxygen saturation problems. Mean induction fractional inspired oxygen was 87% (median 100%) for an average of 56 minutes. Intraoperative fractional inspired oxygen averaged 40% for a mean duration of 8.1 hours. Postoperative oxygen saturation problems, consisting of prolonged intubation, pulmonary edema, dyspnea, tachypnea or desaturation requiring diuresis, occurred in 19 patients (25%). Surgery/anesthesia time, amount of blood transfused, estimated blood loss, fluid balance, type of fluid given (all p < 0.0001) and preoperative forced vital capacity (p = 0.012) were significant predictors of postoperative oxygen saturation problems on univariate analysis. On multivariate analysis only the amount of blood transfused, preoperative forced vital capacity and surgical time in descending order remained significant. Maintained intraoperative fractional inspired oxygen was not significant on either analysis. There were no deaths.

CONCLUSIONS

Perioperative oxygen restriction in patients treated with bleomycin is not necessary. Intravenous fluid management, including transfusion, appears to be the most significant factor affecting postoperative pulmonary morbidity and overall clinical outcome. In addition, post-chemotherapy forced vital capacity and operative time are significant predictive factors of procedure related pulmonary morbidity.

Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma

PURPOSE

We report stage specific followup guidelines based on our evaluation of the pattern of recurrence in 286 patients treated for local N0 or Nx renal cell carcinoma.

MATERIALS AND METHODS

We retrospectively reviewed the clinical records of 286 patients with pT1 to pT3N0 or Nx renal cell carcinoma who underwent nephrectomy at our center between February 1985 and December 1994. In cases of later metastases the median interval to first metastasis, site of metastasis and method of diagnosis were correlated with the primary lesion stage.

RESULTS

Metastases developed in 68 patients a median of 23 months after nephrectomy. Eight of the 113 patients with pT1 disease had metastases (median time to diagnosis 38 months), while 17 of 64 with pT2 disease and 43 of 109 with pT3 disease had metastases (medians 32 and 17 months, respectively). Of the 92 metastases 59 (64%) were asymptomatic, including 44 detected on routine chest x-rays (32) and blood tests (12). Isolated asymptomatic intra-abdominal metastases were diagnosed by surveillance computerized tomography in only 6 patients (9%). The remaining patients with metastases had associated clinical symptoms and/or abnormal results on interval tests that prompted further diagnostic studies.

CONCLUSIONS

We confirmed that the risk of metastatic renal cell carcinoma is stage dependent. Therefore, surveillance protocols should be based on the pathological stage of the primary tumor. We recommend an annual chest x-ray, and serum liver function and alkaline phosphatase level tests for patients with pT1 disease. These studies are indicated beginning at 6 and 3 months for pT2 and pT3 disease, respectively, continuing every 6 months for 3 years and then annually. Surveillance computerized tomography should be performed at 24 and 60 months in patients with pT2 and pT3 disease or earlier when the results of any routine study are abnormal or clinical symptoms are present. Bone and brain surveillance studies should be prompted by site specific symptoms, elevated alkaline phosphatase levels or the diagnosis of metastasis at another site.

Timely delivery of biological therapy after cytoreductive nephrectomy in carefully selected patients with metastatic renal cell carcinoma

PURPOSE

We determine whether cytoreductive surgery delays or precludes the administration of systemic biological therapy in patients with previously untreated metastatic renal cell carcinoma.

MATERIALS AND METHODS

We evaluated 79 patients 22 to 73 years old with untreated renal cell carcinoma for possible cytoreductive surgery before the administration of systemic biological therapy. Based on performance status, overall disease burden and subjective clinical assessment 13 patients were referred for initial systemic biological therapy and 66 underwent cytoreductive surgery as initial treatment. We evaluated patient ability to receive postoperative biological therapy, time to therapy, surgical complications and mortality.

RESULTS

Cytoreductive surgery had a minimal impact on the administration of timely systemic biological therapy in these carefully selected patients. Of the 66 patients 54 (82%) received postoperative systemic biological therapy beginning a median of 40 days after nephrectomy. Two patients (3%) died postoperatively (within 30 days) and in 1 (1.5%) postoperative deterioration in performance status precluded the administration of systemic therapy. The other 9 patients did not have measurable residual disease postoperatively, did not need or refused systemic therapy, or were followed elsewhere.

CONCLUSIONS

Systemic biological therapy can be administered in a timely manner (median 40 days) to the majority of patients (82% treated) after cytoreductive surgery. Surgery alone does not preclude the administration of systemic biological therapy in carefully selected patients.

Nephrectomy and vena caval thrombectomy in patients with metastatic renal cell carcinoma

OBJECTIVES

To report out experience with performing nephrectomy and vena caval thombectomy in patients with metastatic renal cell carcinoma.

METHODS

A retrospective review was performed of 15 patients who underwent surgical excision of the primary tumor and a caval thrombus and treatment of concurrent metastases between 1989 and 1995. The sites of metastases included lungs (n = 8), bone (n = 3), bulky retroperitoneal or mediastinal lymph nodes (n = 2), liver (n = 1), and contralateral adrenal (n = 1). The level of caval involvement was suprahepatic in 3 cases, retrohepatic in 2 cases, and infrahepatic in 10 cases. Three patients had an Eastern Cooperative Oncology Group performance score of 0, 11 had a score of 1, and 1 had a score of 2. Median follow-up was 17 months.

RESULTS

Median operative time was 6.5 hours and median hospitalization was 10 days. Two patients required re-exploration for postoperative hemorrhage. There were no perioperative deaths. Four patients underwent surgery for resection of solitary metastases (1 lung, 2 spine, and 1 humerus); 2 of the 4 received adjuvant radiotherapy. Two patients received biologic therapy preoperatively, 3 received it both preoperatively and postoperatively, and 6 received it only postoperatively. The median time to initiation of postoperative biologic therapy was 48 days (range 25 to 110). Eleven patients are currently alive, 7 with no evidence of disease at a median follow-up of 17 months (range 6 to 66) and 4 with stable metastases at 14 months (range 4 to 22). Ten of the 13 symptomatic patients had improved performance scores after surgery. Four patients have died from metastatic disease: 2 from rapid progression at 2 and 5 months after surgery and the other 2 at 17 and 42 months.

CONCLUSIONS

Nephrectomy and vena caval thrombectomy can be safely performed in selected patients with metastatic disease. Furthermore, in patients receiving biologic therapy, nephrectomy may enable a better quality of life and prolonged survival.

Staging and prognosis of T3b bladder cancer

Individuals with extravesical extension of bladder cancer (stage T3b) have a worse prognosis than those with muscle-invasive disease confined to the bladder. Accurate staging of T3b bladder cancer becomes increasingly important as more effective methods of treating high-stage bladder cancer are developed. Despite aggressive attempts over the last three decades to stage muscle invasive disease more accurately, bladder cancer is still staged incorrectly in 30% to 50% of patients. The basis for accurate clinical staging resides in a thorough endoscopic resection and a careful bimanual examination. Imaging studies (transurethral ultrasonography, computed tomography [CT], and magnetic resonance imaging [MRI] can increase the accuracy of staging but are most reliable when performed before transurethral resection.

The allergenic properties of fresh and preserved Hevea brasiliensis latex protein preparations

The allergenic properties of the proteins of two lyophilized fractions of fresh natural rubber latex obtained by ultracentrifugation, the C serum and the sedimented bottom or lutoid fraction, have been compared with those of the serum proteins of two samples of high ammonia latex (HAL) [A]HALS obtained from HAL stored for more than 1 year, and [M]HALS derived from HAL stored for 6 weeks before ultracentrifugation and lyophilization. The most potent source of allergenic polypeptides both for skin prick testing of latex-sensitive patients and for immunoblots of their blood serum was the lutoid fraction of fresh latex. Skin prick tests and immunoblots of patients' sera showed that the allergenicity of the ammoniated latex decreased during storage. Skin prick tests using fractions of [A]HALS, C serum and lutoid proteins obtained after passage through a Sephacryl S300 column showed that the components of all three preparations which eluted in the largest volumes were almost equally effective in provoking the largest number of responses. Immunoblots of the sera of 43 latex-sensitive individuals showed that the majority (66%) of sera of the adult allergic patients reacted with a polypeptide of 19 kD. No characteristic pattern of binding latex polypeptides could be recognized in the sera from patients who were also asthmatic or from those who had an anaphylactic response to latex proteins.

Effect of human chorionic gonadotropin before spermatic vessel ligation in the prepubertal rat testis

After single stage Fowler-Stephens orchiopexy testicular atrophy is common. Previous experimental study in the scrotal testis of the adult rat has shown that ligation of the internal spermatic artery often causes focal testicular infarction or atrophy and exogenous human chorionic gonadotropin increases testicular blood flow. We questioned whether division of the internal spermatic artery in the undescended rat testis would also cause testicular injury and hypothesized that these changes might be prevented by administering human chorionic gonadotropin before vessel ligation. Two groups of 20-day-old Sprague-Dawley male rats were subjected to unilateral internal spermatic artery ligation. Group 1 (control) received no human chorionic gonadotropin, while group 2 received 10 IU human chorionic gonadotropin daily from days 3 to 17 of life. At 3 months testicular blood flow was quantitated using 141cerium radioactive microspheres. The results indicated that blood flow on the operated side was lower than on the nonoperated side but the change was not statistically significant. Human chorionic gonadotropin had no effect on blood flow to the operated testes. Gross testicular weights of operated versus nonoperated gonads were similar in rats that did and did not receive human chorionic gonadotropin. Pathological evaluation revealed normal histology in all testes. These results do not support the use of human chorionic gonadotropin preoperatively to stimulate collateral testicular blood flow.

Laparoscopic pelvic lymphadenectomy and radical perineal prostatectomy: a viable alternative to radical retropubic prostatectomy

Laparoscopic pelvic lymphadenectomy and radical perineal prostatectomy performed under the same anesthetic provide accurate surgical resection of localized carcinoma of the prostate with reduced intraoperative blood loss, minimal postoperative discomfort, short hospital stay (mean 4.1 days), high level of postoperative continence (81% completely dry after 4 months postoperatively) and low morbidity (4 complications). The clinical records of 37 patients undergoing this combined procedure during the last 22 months were reviewed retrospectively and the efficacy of the procedure was evaluated. This combined treatment modality avoids an abdominal incision and pelvic drains, and is associated with minimal postoperative discomfort and a short hospital stay. Laparoscopic pelvic lymphadenectomy combined with radical perineal prostatectomy is an alternative to open pelvic lymph node dissection and radical retropubic prostatectomy.

Simple narcotic kits for controlled-substance dispensing and accountability

Operating rooms require a storage, dispensing and accounting system for restricted drugs which satisfies narcotics control authorities and is compatible with efficient care of patients. We describe narcotic kits containing fentanyl-morphine-midazolam, alfentanil-midazolam and sufentanil-midazolam, for general operating rooms, and two kits with larger quantities of fentanyl and sufentanil for cardiac operating rooms. The container for each kit is a video cassette holder which has a foam-rubber liner with sculpted depressions for each ampoule. Sealed kits are delivered each morning from pharmacy to the locked narcotics cupboard in the recovery room. On request, the recovery room nurse unlocks the cupboard and the anaesthetist signs out the required kit(s) for the day. A drug utilization form is enclosed with each kit, on which the anaesthetist records the amount of drug administered to each patient, and before returning the kit to the locked narcotics cupboard, the total amount of each drug used, discarded, and returned. Used kits are collected the following morning by a pharmacy technician who reconciles the contents and drug form of each kit. More than 40 staff anaesthetists and a similar number of residents have used the system for seven years, during which time 130,000 patients have passed through the operating rooms. Detection of one case of drug diversion by a staff anaesthetist was made partly by the control system, but mainly by behavioural changes. The system is simple, inexpensive, and effective and has been well received by the departments of pharmacy, anaesthesia, and nursing.

Psychologic symptoms in asthma and chronic urticaria

Psychologic symptoms of 102 adult patients with asthma and 74 adult patients with chronic idiopathic urticaria, plus 252 normal nonclinical controls and 383 psychologically distressed ('socially isolated') but medically healthy adults were assessed by means of the Brief Symptom Inventory (BSI). On average, both asthma and urticaria patients had more psychopathology-evident in most symptom dimensions of the BSI-than healthy controls but much less than 'socially isolated' adults. Nevertheless, only about 40% of the subjects in both patient groups had above-normal BSI scores. Both men and women with asthma and women with urticaria had BSI scores greater than the normal controls, whereas the scores of men with urticaria were not different from those of healthy men. Thus, about half the women with either disease but less than one man in three with asthma and only about one man in ten with urticaria had significant psychologic distress. Recognition of patients' psychologic symptoms should be useful in planning and managing their medical therapy.

Neonatal testis tumors: a review of the Prepubertal Testis Tumor Registry

Since 1980, 338 testis tumors have been registered in the Prepubertal Testis Tumor Registry of the American Academy of Pediatrics, Section on Urology. Of these tumors 22 occurred in neonates less than 1 month old, of which 7 (31%) were diagnosed at birth. The distribution of lesions in this group revealed 6 yolk sac tumors, 6 gonadal stromal tumors, 6 juvenile granulosa cell tumors, 2 gonadoblastomas, 1 teratoma and 1 hamartoma. Preoperative serum alpha-fetoprotein levels were available for 10 patients and ranged from 23 to 61,700 ng/ml., which is within normal limits. No patient had evidence of metastatic disease at presentation. Of the 18 children in whom follow up is available 17 have no evidence of disease and 1, who was diagnosed with a yolk sac tumor before the advent of chemotherapy, died of metastatic disease before reaching age 1 year. Although neonatal testis tumors are rare, they should be considered in the differential diagnosis and management of a newborn with a scrotal mass.

Giant multilocular prostatic cystadenoma: a rare clinical entity and review of the literature

Giant multilocular prostatic cystadenoma is a pathologically benign entity. To our knowledge only 3 cases have been reported in the literature, of which 2 were treated by means of pelvic exenteration. These lesions can occur in men of various ages, arise from the prostate and grow to massive proportions. Histologically the tumor is comprised of benign cysts lined with cuboidal and columnar epithelium. The lesions do not invade contiguous structures but they can be adherent to viscera in their proximity. Giant multilocular prostatic cystadenoma as demonstrated by our case is a benign entity that can be definitively treated by carefully planned complete surgical excision.

Purification of human IgG4 subclass with allergen-specific blocking activity

Blocking antibodies (bAb) induced by allergen immunotherapy are restricted to the IgG1 and IgG4 subclasses, with IgG1 predominating early and IgG4 coming later. Study of IgG4 bAb has been limited, in part, by the absence of a method to purify IgG4. We describe a rapid immunoaffinity chromatographic method for the purification of that subclass from whole serum. Starting serum (TR) contained 90 micrograms/ml Dactylis glomerata (orchard grass) pollen (DGP)-specific IgG4, measured by indirect ELISA. The blocking activity of TR was assayed in vitro on IgE-sensitized human basophils. Immunoadsorption on a strong-binding anti-IgG4 monoclonal antibody (mAb) removed about 90% of the total and allergen-specific IgG4 and nearly all of the blocking activity from TR. An IgG4-rich fraction was then obtained by absorption of several small volumes of TR on a weak-binding anti-IgG4 mAb column at neutral pH followed by elution with glycine-HCl buffer. The pooled eluates contained 82% IgG4, amounting to a 65-fold purification of the serum IgG4; the yield was approximately 30%. Nearly all the DGP-specific antibody was in the IgG4 component of the eluate. The blocking activity of the eluate was approximately equal to that of TR. Immunoblot patterns with the eluate and with TR on SDS-PAGE of DGP were nearly identical. This method thus provides a fully active, relatively pure IgG4 blocking antibody. Moreover, the results reinforce the importance of using a well-chosen mAb when purifying proteins by immunoaffinity chromatography.