Characteristics of uncontrolled hemorrhage in cardiac surgery

Patients with uncontrolled hemorrhage require massive transfusion therapy and consume a large fraction of blood bank resources. Institutional guidelines have been established for treatment, but early identification and prevention in susceptible patients remains challenging. Uncontrolled hemorrhage was defined as meeting institutional guidelines for recombinant FVIIa administration. Patients who received rFVIIa were compared with patients who did not require the therapy but who were operated on during the same time period. After institutional review board approval, demographic, operative, and transfusion data were analyzed from a prospective database. Patients receiving rFVIIa were more likely to undergo multiple procedures (2.6 +/- 0.8 vs. 1.8 +/- 0.8; p < .001); aortic surgery (59% vs. 11%; p < .005); have a higher Cleveland Clinic Clinical Severity score (7.8 +/- 2.7 vs. 5.5 +/- 4.0; p < .005); require longer bypass (265 +/- 92 min vs. 159 +/- 63 min; p < .001), cross-clamp (182 +/- 68 min vs. 112 +/- 56 min; p < .001), and circulatory arrest (15 +/- 24 min vs. 2 +/- 7 min; p < .05) times; and require more autotransfusion (2580 +/- 1847 mL vs. 690 +/- 380 mL; p < .05). Uncontrolled hemorrhage is associated with more complex surgery requiring longer bypass times and more autotransfusion.

Randomized phase III trials of adjuvant FAMTX or FEMTX compared with surgery alone in resected gastric cancer. A combined analysis of the EORTC GI Group and the ICCG

BACKGROUND

In patients who underwent radical resection for gastric cancer, we investigate the relative efficacy of combined 5-fluorouracil+adriamycin or epirubicin and methotrexate with leucovorin rescue (FAMTX or FEMTX) compared with a control arm.

PATIENTS AND METHODS

This report is a prospective combined analysis of two randomized clinical trials conducted on patients who underwent radical resection for histologically proven adenocarcinoma of the stomach or esophago-gastric junction. Three hundred and ninety-seven untreated patients, 206 from 23 European Organization for Research and Treatment of Cancer (EORTC) institutions and 191 from 16 International Collaborative Cancer Group (ICCG) institutions, were randomized. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method and the treatments were compared for these end-points by means of the log-rank test, retrospectively stratified by trial.

RESULTS

In a planned combined analysis of the two trials, no significant differences were found between the treatment and control arms for either DFS (hazards ratio: 0.98, P=0.87) or OS (hazards ratio: 0.98, P=0.86). The 5-year OS was 43% in the treatment arm and 44% in the control arm and the 5-year DFS was 41% and 42%, respectively.

CONCLUSION

Neither FAMTX nor FEMTX can be advocated as adjuvant treatment in patients who undergo resection for gastric cancer.

Use of platelet gel and its effects on infection in cardiac surgery

The use of plasmapheresis in cardiac surgery has failed to show an unequivocal benefit. However, the further processing of plasmapheresed blood to obtain a platelet-rich concentrate, termed platelet gel, may reduce patient susceptibility to infection through poorly understood mechanisms related to a combination of platelets, white blood cell content, and expedited wound healing. The purpose of the study was to retrospectively evaluate the incidence wound infections in patients undergoing cardiac surgery. Platelet gel (PG) patients (n = 382) received topical administration of a mixture of platelet concentrated plasma, 10% calcium chloride (5 mL), and bovine thrombin (5000 units). A control group (NoPG, n = 948) operated on concurrently with the treatment group did not receive PG, but otherwise received similar wound care. A historical control (HC, n = 929) included patients operated on before the availability of PG. After Institutional Review Board approval, 20 factors reported in the literature to predispose individuals for increased infection were recorded along with infections classified either as superficial or deep sternal according to the Society of Thoracic Surgeon criteria. All data were obtained from our institutional contribution to the Society of Thoracic Surgeon database. All adult (>19 years of age) patients undergoing cardiac surgery at our institution between October 2002 and June 2005 were included in this study (n = 2259). The incidence of superficial infection was significantly lower in the PG group (0.3%) compared both with the NoPG (1.8%) and HC (1.5%) groups (p < .05). There was a similar relationship found when comparing deep sternal wound infections (PG, 0.0% vs. NoPG, 1.5%; p < .029 and PG vs. HC, 1.7%;p < .01). In conclusion, the application of PG in patients undergoing cardiac surgery seems to confer a level of protection against infection, although the mechanisms of action remain to be elucidated.

Improved outcomes during cardiac surgery: a multifactorial enhancement of cardiopulmonary bypass techniques

Patients presenting for cardiac surgery with cardiopulmonary bypass (CPB) are more likely to have pre-existing comorbidities, which has resulted in a steady increase in the risk associated with CPB. The resulting challenge has mandated the optimization of perfusion care. The purpose of this study was to retrospectively evaluate the impact of a number of simultaneous, evidence based perfusion care changes on patient outcome. After Institutional Review Board approval, two groups of patients were compared. The control group (n = 317) included all patients undergoing CPB in a 12-month period preceding a multifaceted change in perfusion techniques. The treatment group (n = 259) included all patients undergoing CPB in the 12-month period after the changes, which included the incorporation of updated continuous blood gas monitoring, biocompatible circuitry, updated centrifugal blood propulsion, continuous autotransfusion technology, new generation myocardial protection instrumentation, plasmapheresis, topical platelet gel application, excluding hetastarch while increasing the use of albumin, viscoelastographic coagulation monitoring, and implementing a quantitative quality improvement program. After univariate analysis, propensity scoring and multiple conditional logistical regression were used to control for demographic, preoperative, operative, and postoperative parameters. Results of the primary endpoints revealed a lower mortality rate in the treatment group (4% vs. 9% [95% confidence interval 1.33, 7.72], p = 0.009), lower transfusion rate (51% vs. 59% [1.00, 2.11], p = 0.048), and lower complication rate (55% vs. 65% [1.06,2.19], p = 0.025) despite having similar predicted mortality (11 [2,22] vs. 11[3,22], p = NS) and other preoperative and operative parameters. The lower mortality rate was concurrent with a trend towards a lower incidence of complications, consistent with the differences in primary outcomes. In conclusion, the patients treated after the implementation of a multifactorial improvement plan using evidence based changes in CPB care had decreased complication and mortality rates.

High dose chemotherapy and autologous stem cell transplantation as adjuvant therapy for primary breast cancer patients with four or more lymph nodes involved: long-term results of an international randomised trial

BACKGROUND

The purpose of this study was to assess whether a short course of anthracycline containing chemotherapy followed by high dose therapy with autologous stem-cell support improves disease-free and overall survival as compared with conventional, anthracycline containing chemotherapy, in patients with primary breast cancer and four or more histologically involved lymph nodes.

PATIENTS AND METHODS

Two hundred and eighty one patients entered into a randomised clinical trial were allocated to receive standard, conventional treatment (5-fluorouracil, epirubicin and cyclophosphamide-FEC for six cycles) or FEC for three cycles followed by high dose therapy consisting of cyclophosphamide, thiotepa and carboplatin and stem cell rescue (HDT). To be eligible, patients had to be free of overt metastatic disease and be < or =60 years of age. Analyses were according to intention to treat.

RESULTS

At a median follow up of 68 months, 118 patients have experienced a relapse or death from breast cancer (62 in the FEC followed by HDT arm and 56 in the conventional FEC arm) and a total of 100 patients have died (54 in the FEC followed by HDT arm and 46 in the conventional FEC arm). No significant difference was observed in relapse-free survival [hazard ratio 1.06, 95% CI 0.74-1.52, p = 0.76] or overall survival [hazard ratio 1.18, 95% CI 0.80-1.75, p = 0.40]. Five patients died from treatment related causes, three as a consequence of HDT and two in the conventional FEC arm.

CONCLUSIONS

At the present time, no benefit has been observed from replacing three cycles of conventional chemotherapy with the HDT regimen described here. Patients should continue to receive conventional chemotherapy as adjuvant therapy for breast cancer.

Comparative efficacy and safety of celecoxib and naproxen in the treatment of osteoarthritis of the hip

Osteoarthritis (OA) is responsible for more disability of the lower extremities in the elderly than any other disease in the US. The pain associated with OA is the primary symptom leading to disability in these patients. Current ACR guidelines recommend consideration of acetaminophen for mild-to-moderate pain and conventional non-steroidal anti-inflammatory drugs (NSAIDs) or COX-2 specific inhibitors for moderate-to-severe OA symptoms. The aim of this study was to compare the efficacy and safety of the COX-1 sparing, COX-2 specific inhibitor, celecoxib, with the conventional NSAID naproxen, and placebo, in the treatment of OA of the hip. In this multicenter, randomized, placebo-controlled trial, 1061 patients with symptomatic OA of the hip were randomized to receive celecoxib at doses of 100 mg, 200 mg, or 400 mg/day; naproxen 1000 mg/day; or placebo, for 12 weeks. Patients were evaluated using standard measures of efficacy at baseline, 2-4 days after discontinuing previous NSAID or analgesic therapy, and after 2, 6, and 12 weeks of treatment. All doses of celecoxib and naproxen significantly improved the symptoms of OA, at all time points compared with placebo. This sustained treatment effect of celecoxib was dose dependent. In terms of pain relief and improvement in functional capacity, celecoxib 200 mg/day and 400 mg/day were similarly efficacious and were comparable to naproxen. Both drugs were generally well tolerated. Celecoxib at a dose of 200 mg/day is as effective as a standard therapeutic dose of the conventional NSAID, naproxen, in reducing the pain associated with OA of the hip.

Quantitative detection of aromatic compounds in single aerosol particle mass spectrometry

Most laser-based aerosol mass spectrometers rely on a single ultraviolet laser to both ablate and ionize the aerosol particle. This technique produces complex and fragmented mass spectra, especially for organic compounds. The approach presented here achieves a more robust and quantitative analysis using a CO2 laser to evaporate the aerosol particle and a vacuum ultraviolet laser to ionize the vapor plume. Vacuum ultraviolet laser ionization produces little fragmentation in the mass spectra, making the identification of an aerosol particle's constituents more straightforward. An analysis of simple, three-component mixtures of aniline, benzyl alcohol, and m-nitrotoluene shows that the technique also provides a quantitative analysis for all the components of the mixture. Furthermore, the detection of predominantly parent ion signal from anthracene particles demonstrates the utility of the technique in the analysis of lower vapor pressure, solid-phase aerosols. Finally, we discuss the potential and limitations of this technique in analyzing organic atmospheric aerosols.

Epirubicin plus tamoxifen versus tamoxifen alone in node-positive postmenopausal patients with breast cancer: A randomized trial of the International Collaborative Cancer Group

PURPOSE

To assess whether the addition of epirubicin (EPI) therapy to prolonged treatment with tamoxifen (TAM) improves relapse-free and overall survival in postmenopausal women with node-positive primary breast cancer.

PATIENTS AND METHODS

Six hundred four patients entered onto a randomized clinical trial were allocated to receive TAM 20 mg/d for 4 years or TAM 20 mg/d for 4 years plus EPI 50 mg/m(2) intravenously on days 1 and 8 every 4 weeks for six cycles. Analysis was performed according to allocated treatment, with all randomized patients included (intention to treat), irrespective of eligibility status.

RESULTS

After a median follow-up period of 5.7 years, an improvement in relapse-free survival (RFS) was observed for the TAM and EPI-treated patients, compared with those who received TAM alone. The unadjusted hazard ratio was 0.72 (95% confidence interval, 0.54 to 0.96), with a corresponding reduction in the odds of recurrence of 27.9% (SD, 12. 3), which was statistically significant (P =.023). Adjustment for prognostic and/or predictive factors did not materially affect the hazard ratio. No difference was observed in terms of overall survival (reduction in odds of death, 11.9% [SD, 16.3]; P =.46). Combined chemohormonal treatment was associated with a higher incidence of acute side effects but without a clear increase in long-term cardiotoxicity. Twelve nonbreast second malignancies, including five hematologic malignancies (two of which were cases of acute myelogenous leukemia), were observed.

CONCLUSION

The data show that combined chemohormonal treatment reduces the risk of relapse in postmenopausal patients with node-positive breast cancer. No evidence was found, however, for an improvement in overall survival. The size of benefit observed for both outcomes was consistent with that reported in the Early Breast Cancer Trialists' Collaborative Group overview. The trial presented here, however, provides the first report of an improvement in RFS associated with the provision of a single cytotoxic drug in addition to prolonged TAM.

Survival of patients with limited-stage small cell lung cancer treated with individualized chemotherapy selected by in vitro drug sensitivity testing

Our purpose was to study the feasibility of determining individualized chemotherapy regimens by in vitro drug sensitivity testing (DST) for patients with limited-stage small cell lung cancer (SCLC) and to evaluate patient response and survival. Fifty-four previously untreated patients with limited-stage small cell cancer were studied. Fresh tumor specimens for DST were collected, when possible, from patients' biopsies before the start of treatment. The differential staining cytotoxicity assay was used to determine the in vitro sensitivity of the tumor cells to different drugs. From these results, an in vitro best regimen (IVBR), a three-drug combination of previously proven efficacy of seven active drugs in SCLC, was selected. Patients were initially treated with four cycles of etoposide/cisplatin and concurrent radiotherapy. This was followed by four cycles of either individualized chemotherapy regimens based on the results of DST or, when DST results were not available, four cycles of vincristine, doxorubicin, and cyclophosphamide. Eighteen patients (33%) underwent biopsy procedures that provided tissue specimens for DST. The biopsy specimens contained tumor cells in 16 of 18 patients. The median duration from diagnosis to start of treatment was 22 days (range, 4-58 days) for the 18 patients who underwent elective thoracic biopsies compared to 21 days (range, 2-74 days) for members of the group that did not (P2 = 0.58). Time from thoracic biopsy to initiation of chemotherapy was a median of 4 days (range, 2-22 days). DST was done in 10 patients, and IVBR was administered to 8 patients. The median actuarial survival of 8 patients treated with their IVBR was 38.5 months compared to 19 months for the 46 patients treated with empiric chemotherapy. Selection of individualized chemotherapy regimens is labor intensive but feasible in limited-stage SCLC. Treatment with an individualized IVBR in our patients was associated with prolonged patient survival; however, because of the nature of our study design, other factors could have affected the results.

Surfactant treatment and ventilation effects on surfactant SP-A, SP-B, and SP-C mRNA levels in preterm lamb lungs

The effects of exogenous surfactant treatment combined with postnatal ventilation on surfactant protein (SP)-A, SP-B, and SP-C steady-state mRNA levels were evaluated in preterm sheep at 120, 132, and 139 days gestation. Three groups were studied at each gestation period: animals ventilated and treated with 100 mg/kg natural sheep surfactant, animals ventilated and not treated with surfactant, and a comparison group of lambs that were neither ventilated nor treated with surfactant. In unventilated lambs, SP-A and SP-C mRNA levels measured by densitometry from Northern blots increased between 120 and 132 days gestation (P < 0.05). At 120 days gestation, no differences in SP-A, SP-B, or SP-C mRNA levels were noted among the three groups. At 132 days gestation, SP-A mRNA levels increased in both ventilated groups (P < 0.01), but no additional surfactant effect on SP-A mRNA expression was detected. There were no changes in SP-B or SP-C mRNA levels among the groups at 132 days gestation. At 139 days gestation, mRNA levels for both SP-A and SP-B increased after ventilation, compared with the unventilated groups (P < 0.05). Furthermore, an additional effect of surfactant treatment to increase SP-A mRNA levels relative to animals undergoing ventilation alone was noted (P < 0.05). We conclude that postnatal changes in mRNA levels for the surfactant proteins are gestationally regulated and protein specific.

Postnatal renal adaptation in preterm and term lambs

The present experiments determined if increases in renal reabsorptive capacity during the transition from fetal to neonatal life are gestation dependent. Renal function was studied in chronically-catheterized fetal lambs (133 +/- 1 days; term, 145-150 days). Additionally, renal function was studied in anaesthetized, ventilated, caesarean-delivered preterm lambs (109-139 days gestation) and term lambs (148 days gestation), and in 2-day-old spontaneously-delivered term lambs. Newborns < or = 120 days old received surfactant to facilitate ventilation and maintenance of physiologic blood gases. Two hours after caesarian delivery, urine osmolality, urine flow, glomerular filtration rate (GFR), and fractional sodium excretion (FENa) values were similar for all gestations. Relative to fetal values, caesarean-delivered newborn renal values included lower urine flow rates (0.20 +/- 0.03 v. 0.05 +/- 0.01 mL min-1 kg-1), higher urine osmolalities (118 +/- 15 v. 422 +/- 16 mOsmol kg-1 H2O), and no differences in GFR or FENa. Relative to caesarean-delivered newborns, 2-day newborn renal function included higher values for GFR (0.7 +/- 0.1 v. 3.0 +/- 0.1 mL min-1 kg-1) and urine osmolality (724 +/- 32 mosmol kg-1 H2O), and lower FENa (7.0 +/- 1.5 v. 0.2 +/- 0.02%), and urine flow (0.005 +/- 0.003 mL min-1 kg-1). The 132- and 139-day animals were ventilated for 5 h and 10 h respectively; the only functional change at 10 h was a decrease in FENa (7.0 +/- 1.5 v. 2.8 +/- 0.1%). It is concluded that: (1) relative to fetal animals, renal adaptive responses in anaesthetized, ventilated newborns begin within 2 h following caesarian delivery; (2) initial adaptive responses are not gestation dependent after 109 days; and (3) the combined effects of ventilation and/or anaesthesia delay postnatal renal adaptations for at least 10 h after birth.

Surfactant protein A labeling kinetics in newborn and adult rabbits

Surfactant protein A (SP-A), the major hydrophilic protein specifically associated with surfactant, has multiple metabolic and host defense functions as well as primary surfactant biophysical functions in association with the other surfactant proteins and lipids. To characterize its kinetics of secretion and clearance from the airspace, we measured specific activity-time curves for alveolar and lamellar body associated SP-A following the intravascular and/or intratracheal administration of the radiolabeled precursors Tran 35S-label containing primarily methionine and cysteine or [3H]methionine to newborn and adult rabbits. Alveolar SP-A specific activity peaked 30 min after precursor injection in both newborn and adult rabbits, and labeled SP-A was not detected in lamellar bodies until after 2 h. In newborns, a second peak of labeled SP-A appeared at 15 h. In both newborns and adult rabbits, lamellar body specific activity-time curves were most consistent with SP-A entering lamellar bodies via a recycling pathway from the airspaces. The airspace clearance of SP-A in adult rabbits had a biologic half-life of about 4.5 h. There was very little decrease in SP-A specific activity in the newborn rabbits, indicating minimal catabolism. These studies demonstrate secretion of endogenously synthesized SP-A by a pathway separate from lamellar bodies. The kinetics of secretion of SP-A and the surfactant phospholipid in newborn and adult rabbits indicate separate metabolic pathways.

Double-blind comparison of the efficacy of diclofenac/misoprostol and diclofenac in the treatment of rheumatoid arthritis

A double-blind, randomised, parallel-group study was conducted in eight countries to compare the efficacy of a fixed combination of diclofenac sodium (50 mg) and misoprostol (200 mcg) with a fixed combination of diclofenac sodium (50 mg) and placebo in treating the signs and symptoms of rheumatoid arthritis (RA). A total of 346 patients with RA who had been stabilised on diclofenac for at least 30 days were randomly assigned to receive either diclofenac/misoprostol BID or TID (n = 177) or diclofenac/placebo BID or TID (n = 169) for 12 weeks. Primary analyses of efficacy, made upon admission and at 4-week intervals, consisted of physician's global assessment of the arthritic condition, patient's global assessment of the arthritic condition, patient's global assessment of joint tenderness/pain, and physician's assessment of joint swelling. In this study, the fixed combination tablet of diclofenac sodium 50 mg/misoprostol 200 mcg administered BID or TID demonstrated no statistically significant difference in efficacy in the treatment of the signs and symptoms of RA compared with diclofenac sodium 50 mg/placebo administered BID or TID.

Design and rationale of a randomised comparison of cyclophosphamide, methotrexate and fluorouracil vs fluorouracil, epirubicin and cyclophosphamide in node-positive premenopausal women with operable breast cancer. A trial of the International Collaborative Cancer Group (ICCG)

In 1984, the International Collaborative Cancer Group (ICCG) started a randomised trial comparing adjuvant treatment with cyclophosphamide 100 mg/m2 orally on days 1 to 14, methotrexate 40 mg/m2 intravenously on days 1 and 8 plus fluorouracil 600 mg/m2 intravenously on days 1 and 8 every 4 weeks for 6 cycles (CMF) vs fluorouracil 600 mg/m2, epirubicin 50 mg/m2 and cyclophosphamide 600 mg/m2 (FEC), all given intravenously on day 1 for 8 cycles at 3-week intervals in premenopausal patients with node-positive breast cancer. However, a large French institution that joined the ICCG shortly after the trial was initiated utilised different schedules of both CMF and FEC. Because different dose intensities were also employed, particularly of FEC, both patient groups, the French and non-French, will be analysed separately. A total of 761 patients were randomised as of March 1992. Patients were well balanced for prognostic factors. The median follow-up is now 3.5 years. Preliminary data have previously been reported in abstract form. Final data will be presented pending further follow-up.

Misoprostol heals gastroduodenal injury in patients with rheumatoid arthritis receiving aspirin

High-dose aspirin therapy for rheumatoid arthritis is frequently associated with severe gastrointestinal injury. To explore the possibility of reversing such damage, we conducted a double-blind, multicenter study with misoprostol, a prostaglandin E1 analog, which has demonstrated mucosal protective, gastric antisecretory, and ulcer healing properties. We also studied possible interference of misoprostol with continuing aspirin treatment in the management of patients with rheumatoid arthritis. Patients with confirmed rheumatoid arthritis and endoscopically documented gastroduodenal lesions were randomly assigned to receive 200 micrograms of misoprostol four times a day (123 patients) or placebo (116 patients). Each concurrently received 650 to 1300 mg of aspirin four times a day. After eight weeks of treatment, misoprostol was statistically superior to placebo in healing gastric mucosal injury (70% vs 25%) and duodenal mucosal injury (86% vs 53%). Patients with gastric or duodenal ulcers on admission had superior ulcer healing rates with misoprostol (67% vs 26%). There was no evidence of interference with the antirheumatic properties of aspirin. Mild to moderate adverse experiences were equally noted in misoprostol and placebo groups. Misoprostol, coadministered with aspirin, is well tolerated and highly effective in healing aspirin-associated gastroduodenal lesions in patients with rheumatoid arthritis without altering the therapeutic benefits of aspirin.

'Chyloma': a persistent post-traumatic collection in the left supraclavicular region

A patient with traumatic disruption of the thoracic duct resulting in a chylothorax and a 'chyloma' in the left supraclavicular region is described. Supradiaphragmatic ligation of the thoracic duct was necessary for treatment of the chyloma.

Tissue distribution and excretion of tri-(2-ethylhexyl)trimellitate in rats

The disposition kinetics of tri-(2-ethylhexyl)trimellitate (TEHTM), a new plasticizer for polyvinyl chloride (PVC) plastic, was studied in rats following intravenous administration of [14C-carbonyl]tri-(2-ethylhexyl)trimellitate using an oil in water emulsion as the vehicle. The distribution half-life, elimination half-life, and clearance values estimated from the plasma concentration of radioactivity data obtained following iv administration of 10.5 mg/kg of TEHTM (59.9 muCi/kg), were 46.2 min, 5.34 d, and 40.5 ml/kg X h, respectively. Following iv dosage of 15.6 mg/kg of TEHTM (28.0 muCi/kg), significant accumulation of radioactivity was found in the liver, lungs, and spleen, with liver accounting for 72% of the administered dosage at 24 h. Excretion of TEHTM and its biotransformation products was slow, with 21.3% of the administered radioactivity found in the feces and 2.8% in the urine during the 14-d collection period. Biliary excretion seems to be the major route of elimination of TEHTM. The pharmacokinetic data gathered in the present investigation are compared to di-(2-ethylhexyl)phthalate (DEHP), a widely used plasticizer for PVC.

Assessment of the safety of chemicals administered intravenously in the neonatal rat

A 3-day-old neonatal rat model for the safety assessment of various drugs, chemicals, and nutrients administered intravenously is described. This model was used to assess the safety of di(2-ethylhexyl) phthalate (DEHP), cyclohexanone, and a 3:1 mixture of medium and long-chain triglyceride emulsions following subchronic administration using the intravenous route. The administration of DEHP at dosage of 164.8 mg/kg for 18 consecutive days resulted in a small but statistically significant increase in liver weight and SGOT activity. However, no conclusive histopathological alternations could be discerned between livers from DEHP and normal saline (control) animals. No effects were observed among neonates treated with cyclohexanone at dosages up to 25 mg/kg for 18 consecutive days. Because of technical difficulties emanating from high dosage volumes, the administration of lipid emulsion mixture lasted 9 consecutive days only. Except for transient ataxia and sedation, no adverse effects were observed among neonates that received 3:1 medium- and long-chain triglyceride emulsion for 9 consecutive days beginning on day 3 postpartum. No adverse effects were observed among neonates receiving the lipid emulsions for 7 consecutive days beginning on day 12 postpartum.

Ethylene oxide sensitivity in hemodialysis patients

Sera from 138 patients who had experienced hypersensitivity-type reactions while on hemodialysis (reactors) were examined retrospectively by the radioallergosorbent test (RAST) for specific IgE antibody to ethylene oxide (ETO). Seventy-eight hemodialysis patients without a history of reaction were also evaluated as controls. Elevated serum RAST values (greater than 2.0) were more common in reactors (63%) than in controls (11%, p less than 0.001). In a second study, RAST assays were performed using human serum albumin conjugated to ETO (HSA-ETO) as antigen and also using a concentrate of fluid used to rinse ETO-sterilized dialyzers ("dialyzer extract") as antigen. The RAST ratios obtained with HSA-ETO were similar to those obtained using the dialyzer extract (rank order correlation coefficient = 0.829, p less than 0.001). In a third study, RAST inhibition was demonstrated both by HSA-ETO and dialyzer extract. Our results, extending previously published reports, suggest that hypersensitivity to ETO might play an important role in hemodialysis-associated hypersensitivity-type reactions.

Patella alta and the adolescent growth spurt

The presence of patella alta has been linked to recurrent dislocation of the patella and the patello-femoral stress syndrome. It is not known whether patella alta is an inherited or acquired trait. To investigate the relationship of patella during the adolescent growth spurt, serial orthoroentgenograms (growth study films) were retrospectively analyzed in 19 patients. Two were found in whom proximal patella migration could be correlated (r = 0.85) with femoral growth rate. This was significant at the p = 0.01 level. Girls had a higher correlation of patella height to growth rate than boys. In certain cases, patella alta is an acquired rather than inherited condition; this supports the theory that overgrowth during the growth spurt can lead to patella alta in some individuals.