CD103+ intraepithelial lymphocytes--a unique population in microsatellite unstable sporadic colorectal cancer

Colorectal cancers with microsatellite instability (MSI) typically show increased numbers of intraepithelial lymphocytes (IEL) in comparison to microsatellite stable (MSS) cancers. The aim of this study was to determine the phenotype of this unique lymphocyte population in MSI and MSS colorectal cancers. Twenty-four individuals with sporadic colorectal cancer (17 MSI, 7 MSS) were included in this study. Intraepithelial and stromal lymphocytes were detected using immunohistochemistry with anti-CD8 and anti-CD103 antibodies, and two observers independently quantified the numbers of lymphocytes. CD103+ (alpha E beta 7+) IELs detected within tumour tissue co-expressed CD8+ while the stromal lymphocytes were phenotypically heterogeneous, with respect to CD8+ and CD103+ expression. MSI colorectal cancers harboured increased numbers of CD8+ CD103+ IELs, as well as CD8+ CD103- and CD8+ CD103+ stromal lymphocytes, when compared with MSS colorectal cancers. CD103+ IELs were found at 27-fold greater numbers in the tumour epithelium than in normal epithelium from the same patient (P = 0.001, Wilcoxon matched pairs test). From our findings, we have proposed a mechanism for the homing of these alpha E beta 7+ lymphocytes to tumour tissue in MSI and MSS colorectal cancers.

Melatonin is useful for recording sleep EEGs: a prospective audit of outcome

The study aimed to determine if melatonin could reliably induce sleep in children undergoing sleep EEG without affecting the usefulness of the EEG itself. One hundred and sixty three children (112 males, 51 females; mean age 8 years, range 1 to 16 years) referred for sleep EEG were studied. The children were given 2 to 10 mg of melatonin, depending on age, just before EEG recording. Measurements included sleep-onset latency, adverse effects, and acceptability of the EEG. Usefulness and acceptability of melatonin-induced sleep EEG were compared with the standard technique of sleep EEG following sleep deprivation in 30 children (matched for sex and age). Sleep was obtained in 79% of the 163 children who received melatonin after an average of 33 minutes. Yield of epileptiform abnormalities demonstrated in the melatonin sleep EEG was similar to that reported in the literature for sleep-deprived EEGs. There was no significant adverse effect. When compared, a melatonin-induced sleep EEG was as useful as a sleep-deprived EEG. However, the children's behaviour on the day of the melatonin-induced sleep EEG recording was more acceptable to parents.

Melatonin as a sleep inductor for electroencephalogram recordings in children

OBJECTIVE

To determine the efficacy of melatonin in obtaining sleep electroencephalograms in children.

METHODS

Melatonin was used in 68 unselected children referred to the neurophysiology department for sleep electroencephalogram (EEG). A group of 68 children matched for age and sex who underwent EEGs after sleep deprivation in the same period was used as control. Sleep latency, as well as latency from stage 1 to stages 2, 3 and 4 were measured.

RESULTS

No difference in the number of children who went to sleep was seen. No significant difference is the macrostructure of sleep was seen, other than a reduced sleep latency for the melatonin group (P<0.01).

CONCLUSION

The study suggests that melatonin can reliably be used for obtaining sleep EEGs in children. Its use seems to provide a good alternative to pharmacological sedation and a complementary method to sleep deprivation.

Anticholinesterases in the treatment of Alzheimer's dementia--the first year's experience in Argyll & Clyde

The local experience of the introduction of a new anticholinesterase treatment for Alzheimer's dementia is described, including the use of a protocol to introduce the use of these drugs. The results in the first 233 patients seen are reported. The protocol seemed to anticipate SMAC. guidelines and to be easy to operate; the drug appeared to have clear clinical effect.

The acceptability of sleep-deprived electroencephalograms

The aim of this study was to ascertain the acceptability of sleep-deprived EEGs to parents and their young child. Fifty unselected children having a sleep-deprived EEG were recruited. Data were collected from a sleep diary, a parent questionnaire and the request form of the EEG. Data collected covered developmental, learning and behavioural problems and the acceptability of the sleep-deprived EEG. There were 29 males (58%) in the study group. The average age was 8.6 years (range 2-17 years). Fifty percent of parents found it difficult to keep their child awake at night and 30% of parents found it difficult to wake their child in the morning. Fifty-four percent of parents reported their child had difficult behaviour on the day of the EEG. None had seizures provoked by sleep deprivation.

Delay times in the administration of thrombolytic therapy: the Brighton experience

We reviewed the effectiveness of a strategy involving paramedic ambulances and community education to reduce the delay to thrombolytic therapy in patients admitted with acute myocardial infarction, by analysing delay times recorded during routine treatment. Rapid identification and treatment of patients with acute myocardial infarction who were eligible for thrombolysis was carried out in the Accident and Emergency and Cardiac Care Units. Two hundred seventy-four patients were admitted with acute myocardial infarction over an 18-month period and treated with anistreplase (168) or streptokinase (106). The following median times were recorded: symptom onset to administration of thrombolytic therapy, 142 min (range 43-980 min); symptom onset to ambulance arrival, 60 min; ambulance with patient to arrival in hospital, 35 min; time to treatment in hospital ('door to needle time'), 25 min; in-hospital delays were notably shorter for patients given anistreplase as opposed to streptokinase. Shortened delays for the delivery of thrombolytic therapy can be achieved by a strategy involving public education, the availability of resuscitation ambulances, and close liaison with the Accident and Emergency Department.

Out-of-hospital resuscitation in East Sussex: 1981 to 1989

OBJECTIVE

To assess the impact of extended training in advanced life support on the outcome of resuscitation.

DESIGN

Analysis of the successful resuscitations from 1981 to 1989.

SETTING

Brighton and East Sussex.

RESULTS

248 patients were resuscitated from cardiac or respiratory arrest in the community and subsequently survived to leave hospital. Their mean age was 64 years and one year survival was 77%. In most cases the cause of collapse was cardiac but 38 (15%) suffered a respiratory arrest. In 140 of the successful resuscitations (56%) collapse occurred before the arrival of the ambulance. Basic life support, with ventilation and chest compression where necessary, was sufficient to revive 35 (14%) of the patients. Defibrillation was also required in 107 patients (43%), and in a further 106 patients (43%) who had prolonged cardiorespiratory arrest requiring endotracheal intubation and the use of several drugs. Review of ambulance forms and case notes showed that in 87 cases (35%) the abilities of the paramedical ambulance staff in advanced resuscitation techniques contributed decisively to the success of resuscitation. These skills are illustrated by eight case reports.

CONCLUSIONS

Extended training for ambulance staff increases the likelihood of successful resuscitation from out-of-hospital cardiopulmonary arrest. Though instruction in defibrillation must have the highest priority, full paramedical training can bring appreciable additional benefits.

Medigap preferred provider organizations: issues, implications, and early experience

The Health Care Financing Administration is sponsoring the Medicare Physician Preferred Provider Organization (PPO) Demonstration to assess the feasibility and desirability of including a PPO option under Medicare. Two sites are currently operational. At one site, Blue Cross and Blue Shield of Arizona is offering a PPO linked with a medigap insurance plan. This "medigap PPO" and its initial experience are described, and a preliminary assessment of the viability and effectiveness of medigap PPOs nationally is provided. Impediments to the development and effectiveness of medigap PPOs are identified and possible government actions discussed.

Transcutaneous pacing for cardiac emergencies

Transcutaneous cardiac pacing using the Pace-Aid (Cardiac Resuscitator Corporation) was assessed in 32 emergency patients presenting with profound bradycardia or asystole who had failed to recover with advanced life support including the use of epinephrine. Pacing stimuli, pulse width 20 ms at 50, 100, or 200 mA, were delivered through two 8 cm gel-pad electrodes placed antero-posteriorly on the chest. By ECG criteria, definite electrical capture was achieved in a total of five patients and possible capture in a further 16. Of the 21 patients presenting in asystole 11 showed possible electrical capture only. No evidence of capture was seen in one third of the patients studied. Use of the Pace-Aid resulted in a palpable pulse in a total of seven patients. Four of the 11 patients with profound bradycardia survived to receive temporary transvenous pacing; two were eventually discharged. None in the asystolic group survived. Difficulties in using the Pace-Aid resulted from electrical overload by the pacing impulse that obscured the evidence for electrical capture, and intense muscle contraction that hindered reliable palpation of the arterial pulse. Transcutaneous pacing can occasionally be of value even at a late stage in the emergency treatment of profound bradycardia but is unlikely to be worthwhile in complete asystole.

Imipenem-cilastatin in the treatment of methicillin-sensitive and methicillin-resistant Staphylococcus aureus infections

Imipenem-cilastatin was evaluated for efficacy and toxicity as an antistaphylococcal agent in 23 patients; 11 of these patients were infected with methicillin-resistant Staphylococcus aureus (MRSA), and 12 were infected with methicillin-susceptible S. aureus (MSSA). There were 15 soft tissue, 5 endovascular, and 3 skeletal infections and a total of nine patients with bacteremia. As determined by in vitro susceptibility testing, the MICs for 90% of the MRSA and MSSA isolates tested were 6.25 and 0.39 micrograms/ml, respectively. Two MRSA isolates were resistant to a concentration of greater than 16 micrograms/ml. When 11 MRSA isolates and 7 MSSA isolates were incubated for 48 h the MICs for 90% of the isolates increased to greater than 50 micrograms/ml for the MRSA isolates and 6.25 micrograms/ml for the MSSA isolates. Three S. aureus isolates emerged resistant. Ten of 11 (91%) MRSA infections and 11 of 12 (92%) MSSA infections were clinically cured. Adverse reactions occurred in 25% of the imipenemcilastatin-treated patients. These reactions included gastrointestinal intolerance (7% of the patients), rash or pruritus (6%), eosinophilia (6%), thrombocytosis (4%), and a positive, direct Coomb test without hemolysis (3%). One of the two patients for whom therapy was discontinued because of gastrointestinal intolerance had antibiotic-associated colitis. Imipenem appears to be an effective antistaphylococcal agent against both MRSA and MSSA infections.

Simple mechanical methods for cardioversion: defence of the precordial thump and cough version

A prospective study was made of the value of the precordial thump and of cough version in life threatening ventricular arrhythmias. Of about 5000 medical and surgical patients, 68 were treated for persistent ventricular tachycardia and 248 for ventricular fibrillation, 86 of whom had presented outside hospital. Mechanical intervention was successful in 26 incidents occurring in 23 patients. Electrocardiographic records were obtained in 14 instances. Ventricular fibrillation was terminated by a thump in five patients and ventricular tachycardia by either a thump or a cough in a total of 17 patients. Four additional instances were recorded of successful recovery from asystolic or unspecified circulatory arrest after a precordial thump. Fifteen patients survived to be discharged from hospital. The potential benefit of the precordial thump and cough versions greatly outweighs their risks; hence these manoeuvres should probably be reintroduced into schedules for first aid resuscitation.

A community training scheme in cardiopulmonary resuscitation

Community instruction in basic life support and resuscitation techniques has been offered in Brighton Health District since 1978. Classes are held frequently for the general public and businesses, schools, and other organisations. First aid care for unconscious patients, the treatment of respiratory obstruction or failure, and the recognition and management of cardiac arrest is taught in a single two hour session. Over 20 000 people have been taught, up to 40 at a time in multiple groups of six to eight, by lay instructors usually supervised by ambulancemen trained to "paramedic" standards. Fifty four incidents have been reported to us in which techniques learnt in the classes have been implemented. Five patients recovered after first aid support but subsequently did not seek medical treatment. Of the 34 patients reviewed in hospital, at least 20 survived to be discharged. We believe that intervention may have been life saving in 16 instances. The benefit of cardiopulmonary resuscitation for victims who may have been asystolic is, however, difficult to quantify because the outcome without intervention cannot be predicted accurately. Community training in basic life support should be considered in association with ambulances equipped for resuscitation and hospital intensive care and cardiac care units as an integrated service for the victims of sudden circulatory or respiratory emergencies. The results achieved so far in Brighton and in other more advanced schemes, particularly in the United States of America, may encourage other health authorities to adopt similar programmes.

Five hundred patients with myocardial infarction monitored within one hour of symptoms

Of 2886 patients monitored during acute myocardial infarction, 500 were observed within one hour of the onset of symptoms. Half of the early admission group were admitted in response to emergency 999 calls and 435 of them travelled in resuscitation ambulances, where surveillance for arrhythmias was instituted. Pulmonary oedema occurred in 130 patients (26%), cardiogenic shock supervened in 60 (12%), and 115 (23%) died in hospital. Ventricular fibrillation was observed in 98 patients (20%). Forty two of them survived to be discharged, including 20 of the 24 with primary fibrillation which had occurred first in hospital. In only one case did primary ventricular fibrillation occur after the first 10 hours of onset of illness. Sinus bradycardia, atrial fibrillation, ventricular tachycardia, and ventricular fibrillation were all observed more frequently in patients admitted within one hour after the onset of symptoms than in those admitted later. An element of selection is inevitable when early admission is encouraged by the existence of a resuscitation ambulance system; this will depend in part on the early recognition of risk and the geographical location of the attack. These factors may bias the group towards relatively high risk. Nevertheless, prompt admission after myocardial infarction should improve survival by permitting successful management both of ventricular fibrillation and of other arrhythmias which may influence short term and long term prognosis.

Prevalence of antibody to the Legionnaires' disease bacterium in hospital employees

A sereopidemiologic survey was done to ascertain the level of immunity in a population of hospital employees after contact with patients with Legionnaires' disease. Two matched groups were compared: hospital staff in positions of contact with patients diagnosed with the disease (N1 = 215), and hospital staff not in a position of contact with patients diagnosed with Legionnaires' disease (N2 = 269). Antibody titer was measured by the hemagglutination technique. Subjects from N1 and N2 were surveyed for age, sex, race, smoking, patient care unit, air conditioning unit, occupation, symptoms, and patient contact. No significant correlation was found between titer distribution and any one of the first seven factors. The prevalence of antibody (greater than or equal to 128) was 9.3% and 3.7% (P less than 0.02) for the N1 and N2 groups. Also, 40% of employees with titers of 128 or above had had an unexplained febrile respiratory illness in the preceding year. This study suggests the possibility of person-to-person transmission in Legionnaires' disease.

Experience in the treatment of diabetes at Port Moresby General Hospital

Dietary restriction of refined carbohydrate with regular meals and exercise, preventative foot care, and often daily inulin injections will reduce the mortality and morbidity from diabetes in Papua New Guinea. It is necessary to explain to both the diabetic and their family practical means of treatment including urine tests for glucose. Regular follow up is essential and the establishment of diabetic clinics in major centres would provide the best means of achieving this.

In vitro and clinical studies of cefatrizine, a new semisynthetic cephalosporin

Cefatrizine, a new oral semisynthetic cephalosporin, was evaluated in vitro and in the treatment of 18 patients with acute urinary tract infection, pneumonia, and soft tissue infection. In vitro, it was more active than cephalexin for gram-positive and gram-negative bacteria. It was also more active than cephalothin, cefazolin, and cephapirin against most of the gram-negative bacteria but less active against the gram-positive bacteria. Of the patients treated with cefatrizine, only one failed to respond. This patient had pneumococcal conjunctivitis and hypogammaglobulinemia and neutropenia. The mean peak serum level after multiple 6-hourly doses of 500 mg was 6.2 mug/ml. The serum levels of cefatrizine necessary for inhibition of most susceptible organisms were well within the achievable range. The drug was well tolerated, and no renal, hepatic, or hematological toxicity was detected.

Influenza immunization: clinical studies with ether-split subunit vaccines

Clinical studies of ether-split influenza antigen vaccines have been in progress for almost a decade. One series of such studies, completed before the Hong Kong virus appeared, compared identically constituted conventional and antigen vaccines for serological effectiveness in 1700 vaccinees from the staff of a metropolitan hospital. A series of 6 annual trials included both "old" subjects (vaccinated the previous year) and "new" subjects (no vaccination the previous year). The serological response to the type A2 component of the antigen vaccines was 3-4 times better than that to intact virus in both the old and new populations. The response to either vaccine by new subjects significantly exceeded the response by the old subjects. The type B component of both vaccines induced an equivalent response in both populations. Monovalent Hong Kong vaccines, both conventional and antigen, given just prior to the Hong Kong epidemic induced an anamnestic response in a geriatric group. No influenza-like disease was seen in this high-risk group during the epidemic.

Respiratory Virus Vaccines

The antibody responses of hospital staff volunteers to polyvalent influenza vaccines containing either intact virus or SPEE virus antigens were compared.

Significant increases in HI antibody against each virus strain in both vaccines were observed. Furthermore, postvaccination antibody titers against three of the four strains were significantly greater in the group receiving the SPEE antigens than were those in the group given intact virus.

Evidence that the SPEE antigens may be more efficient antibody stimulators than their intact counterparts is presented and discussed.