Combined topical povidone-iodine and systemic antibiotics in postappendicectomy wound sepsis

Three hundred and fifteen patients with appendicitis were randomized into two groups. One group received pre-operative systemic gentamicin and metronidazole while the other group received 1 per cent topical povidone-iodine solution in addition to the antibiotics. For early appendicitis including normal and acutely inflamed appendices, only one dose of antibiotics was used. The postoperative wound sepsis was very low in both groups of patients and there was no statistical difference between them. For late appendicitis including gangrenous and perforated appendices, the antibiotics were continued for 7 days. Eight out of 51 patients who had the topical agent developed wound sepsis compared with one out of 52 patients who received no topical agent. This difference is statistically significant (P = 0.03). All wound infections presented within 2 weeks of operation and were deep. Povidone-iodine, 1 per cent, adversely affects the wound infection rate in late appendicitis and should not be used.

The posterior "nutcracker": hematuria secondary to retroaortic left renal vein

Retroaortic left renal vein is an uncommon variant in the renal venous system. Recently a patient with such anomaly presented to us with hematuria.

Cefoxitin versus gentamicin and metronidazole in prevention of post-appendicectomy sepsis: a randomized, prospective trial

Three hundred and seven patients with appendicitis were randomized to receive cefoxitin or gentamicin and metronidazole. For early appendicitis, a single preoperative dose of antibiotics was given. For late cases, the antibiotics were continued postoperatively for seven days. Both cefoxitin and gentamicin-metronidazole were effective in the reduction of post-appendicectomy septic complications in early or late appendicitis and there was no statistically significant difference between them. Mild transient and reversible nephrotoxicity was detected in 1.9% of patients who received gentamicin-metronidazole for seven days. Nephrotoxicity was not detected in any other patients. The cost of cefoxitin is higher, but this has to be balanced against the costs of monitoring serum gentamicin and creatinine levels, and the need to adjust the gentamicin dosage in 19% of patients when gentamicin-metronidazole was used. Both cefoxitin and gentamicin-metronidazole are effective and safe when used carefully. Cefoxitin has a slight advantage in its lack of potential nephrotoxicity and ototoxicity.

Ischemic colitis in Kawasaki disease

A case of Kawasaki disease with colonic involvement is reported. Features suggesting ischemic colitis were seen on radiography and at laparotomy. Nonresective approach coupled with aspirin therapy successfully treated the colonic lesion.

A general method for isolation of Mu d1-8(Aprlac) operon fusions in Salmonella typhimurium LT2 from Tn10 insertion strains: chlC::Mu d1-8

A general method was developed for the isolation of Salmonella typhimurium LT2 Mu d1-8 (Aprlac) operon fusions in a gene displacing a Tn10 insertion. Random Mu d1-8 fusion pools were prepared to grow phage P22 lysates which transduced chlC::Tn10 to AprTets on fusaric acid-ampicillin plates. Among these AprTets potential chlC::Mu d1-8 fusions, a simple spot test identified the fusions that were closely linked to the Tn10 insertion in chlC. Out of 68 AprTets isolates 7 chlC::Mu d1-8 fusions with a nitrate-induced Lac+ phenotype were obtained. When oxrA::Tn10 was transduced into these chlC::Mu d1-8 fusions, they became Lac- even in the presence of nitrate, confirming that they were chlC::Mu d1-8 fusions.

Unusual esophageal ulcers containing enveloped viruslike particles in homosexual men

Eight homosexual men presented with odynophagia. Five had a maculopapular rash and 2 had oral ulcers. Upper panendoscopy revealed the presence of multiple discrete ulcers measuring 3 mm-1.5 cm in diameter in the esophagus of each patient. The intervening mucosa appeared normal. Endoscopic brushings and biopsy specimens taken from the ulcer margins and examined by light microscopy showed no inclusion bodies or giant cells. Fungal stains were negative. Biopsy specimens examined by electron microscopy revealed enveloped virus-like particles 100-140 nm in diameter, exhibiting morphologic features consistent with retroviruses. No virus was isolated after incubation in either rhesus monkey kidney or human foreskin fibroblast culture. Serology for cytomegalovirus and herpes simplex virus was consistent with past infection. In each patient the esophageal ulcers healed completely. In summary, an illness characterized by the presence of esophageal ulcers is described in 8 homosexual men, 5 of whom also had a skin rash and 2 of whom had oral ulcers. The cause of the esophageal ulcers is likely to be the enveloped viruslike particles observed at electron microscopy.

Regional distribution of immunoreactive-thyrotrophin-releasing hormone and substance P, and indoleamines in human spinal cord

The regional distributions of thyrotrophin-releasing hormone (TRH) and substance P in postmortem human spinal cord were determined by radioimmunoassay in fresh tissue taken from 22 patients who died without known neurological disease. Dorsal, ventral, and intermediolateral spinal cord regions were obtained from different segmental levels (lumbar L1, 2, 3, and 4; thoracic groups T1-3, T4-6, T7-9, and T10-12) together with selective regions of grey matter of lumbar spinal cord. The effects on peptide levels of the age of the patient, the postmortem time interval, and freezing the tissue samples prior to assay were assessed. Levels of 5-hydroxytryptamine (5-HT) and 5-hydroxyindoleacetic acid (5-HIAA) were determined in regional lumbar and thoracic tissue using HPLC with electrochemical detection. Substance P was found in the highest concentration in the dorsal spinal cord, with no significant segmental differences. In contrast, TRH was present in higher levels in the ventral rather than the dorsal spinal cord, with segmental differences. There was a significant difference in the 5-HT/5-HIAA ratio between dorsal and ventral spinal cord, with the highest ratio in the ventral spinal cord. There were no significant differences in substance P, TRH, or 5-HT levels in spinal cords between 5 and 20 h postmortem or from patients aged between 65 and 90 years. Freezing the tissue (-80 degrees C for 24 h) prior to assay significantly reduced TRH and substance P levels compared to samples assayed immediately without prior freezing.(ABSTRACT TRUNCATED AT 250 WORDS)

Intra-operative fibreoptic enteroscopy for bleeding lesions in the small intestine

Twenty-five patients with gastrointestinal bleeding proved to have lesions in the small intestine. Intra-operative fibreoptic enteroscopy was performed on seven patients, in six patients through the anus and in one patient through an enterotomy and the anus. The indications for fibreoptic enteroscopy were inability to find the lesions in the 3 patients, multiple small lesions in 3 patients and to rule out suspicious pathology in the jejunum shown on a small bowel enema in a patient with ileal ulcers. In all instances, the fibreoptic enteroscopy was useful in localizing lesions, in detecting additional lesions and in ruling out the suspicious lesions. It can be performed easily and is safe. No complication developed from its use in this series.

The clinical significance of routine histopathologic study of the resected appendix and safety of appendiceal inversion

A prospective study was done on 1,699 patients operated upon for appendicitis to correlate the operative diagnosis of the surgeon and the histopathologic diagnosis of the pathologist. There are surgeons who only send the appendices for histopathologic study when the operative findings are inconclusive and surgeons who invert rather than resect the appendices on finding a grossly normal appendix at operation. This study was done to find out whether or not these practices of leaving some of the appendix unexamined histopathologically are clinically safe. In this study, surgeons missed abnormal pathologic findings in the appendix in ten of 13 patients and this is irrespective of whether the appendix was normal, acutely inflamed, gangrenous or perforated. The majority of these lesions either require further investigation, treatment or they affected the prognosis of the patient. Nineteen per cent of the patients diagnosed as having normal appendices grossly were found to have acute appendicitis and 7.7 per cent diagnosed as acute appendicitis were normal. Based upon these data, we conclude that the operative diagnosis of the surgeon cannot be relied on to detect abnormal pathologic findings in the appendix. Additional important clinical information can be gained by routine histopathologic study of the resected specimens, and inversion of the appendix is clinically not safe.

The problem of home management in the estimation of the incidence of acute myocardial infarction from hospital records

Past studies of the incidence of acute myocardial infarction (AMI) have found information for patients managed at home difficult and expensive to obtain. This study attempted to find whether the efficiency of gathering this information could be improved, or if this group of patients could be neglected entirely. A random sample of 270 doctors in Perth were asked about their management of cases of suspected AMI at home. Of these doctors, 78% said that they never managed AMI at home; excluding such doctors before seeking voluntary notification of new cases managed at home could make population surveys of AMI more efficient. For patients under 65 it was estimated that about 1% or less of non-fatal cases meeting World Health Organization criteria for definite AMI were managed at home. Thus neglecting this group would probably cause little bias in computing incidence rates for AMI in Perth.

Randomized, prospective, and double-blind trial of new beta-lactams in the treatment of appendicitis

A prospective, randomized, and double-blind study was conducted with 864 patients operated on for appendicitis. In early cases, including normal and acute appendicitis, one dose of antibiotic was given. The rate of postappendectomy septic complications in patients who received cefotaxime, cefoperazone, or moxalactam was very low (about 3%), and there was no statistical difference between the drugs. For late cases, including gangrenous and perforated appendicitis, the antibiotics were continued for 5 days. Moxalactam decreased significantly the septic complications in these patients when compared with the other two drugs. It is safe, free from serious toxic side effects, and more convenient and easier to administer than combination antibiotic therapy. The main disadvantage of moxalactam is its high cost, but this has to be balanced against the savings in nursing time, the cost of monitoring renal function and serum level when aminoglycosides are used, and the reduced usage and manipulation of infusion sets.

Micturition after cystoplasty

In patients with advanced carcinoma of the bladder not involving the trigone, radical total cystectomy with bladder replacement (replacement cystoplasty) using either the colon, ileum or stomach can be performed. In male patients, the prostatic urethra is always included in the resection so that the extent of radical surgery is not compromised. Thus the neobladder is anastomosed to the membranous urethra in these patients. In patients with contracted tuberculous bladder, the neobladder is anastomosed to the trigone after subtotal cystectomy (augmentation cystoplasty). The pattern of micturition is studied in 32 patients with cystoplasty after cystectomy. Emptying of the neobladder is achieved and completed mainly by abdominal straining rather than by the spontaneous contraction of the gastrointestinal segment, as evidenced by cystometric studies. The stomach generates high pressures during its peristaltic contractions but this could be a disadvantage during the early postoperative period particularly in the females, as urinary incontinence may result. In the majority of patients, micturition takes place every 2 to 3 hours with full urinary continence during the waking hours. However, in patients after radical total cystectomy, incontinence of urine during deep sleep is inevitable. No differences of voiding pattern, bladder capacity and residual urine volume are noted when either the colon, ileum or stomach is used for cystoplasty.

The formaldehyde-donating activity of N5,N10-methylene tetrahydrofolic acid in xenobiotic biotransformation

Reaction of reproterol, (7-(3-[2-(3,5-dihydroxyphenyl)-2-hydroxyethylamino]propyl)theophyl line (I), with formaldehyde liberated in a solution of N5,N10-methylene tetrahydrofolic acid at pH 7.3 led to the formation of 7-[3-(4,6,8-trihydroxy-1,2,3,4-tetrahydroisoquinolinyl-2)propyl]th eophylline (II), but no such reaction was observed in a solution of N5-methyl tetrahydrofolic acid. Compound II was also formed by incubation of I with rat-liver subcellular fractions. The highest formaldehyde-donating activity was found in the soluble fraction but some activity was also observed with washed mitochondria and microsomes. Dimedone was transformed to methylene bisdimedone by incubation with the soluble fraction. The amount of formaldehyde liberated in the soluble fraction during a four hour incubation at 22 degrees C was 1-3.6 mumol/g of liver. Metaproterenol and terbutaline, structurally related to I, reacted with formaldehyde to yield the corresponding tetrahydro-isoquinolines. The rate of this chemical reaction for the three drugs correlated with the amount of the tetrahydroquinolines formed by incubation with the soluble fraction and in orally dosed rats.

Facilitation of ganglionic response to bethanechol by repetitive stimulation of the preganglionic nerve

Repetitive stimulation of the preganglionic nerve of the rat superior cervical sympathetic ganglion potentiates the amplitude of asynchronous firing elicited by the muscarinic agonist, bethanechol. The amplitude of stimulus-induced facilitation is not related to frequency of stimulation and occurs with a stimulation frequency of 10 Hz or greater. Facilitation, but not the asynchronous firing is reduced by lowering the temperature of the bathing solution. Dibutryl cyclic adenosine monophosphate and theophylline had no effect on asynchronous firing but reduced stimulus-induced facilitation. Neither dibutryl cyclic guanosine monophosphate up to 1 mM nor nitroprusside had any significant effect on bethanechol-induced asynchronous firing or stimulus-induced facilitation. Tetraethylammonium caused a 200% increase in stimulus-induced facilitation. Acetylcholine, in a concentration that elicited maximum nicotinic firing, had no effect on the magnitude of bethanechol-induced asynchronous firing. Increased Ca++, Mg++ or Mn++ reduced both asynchronous firing and stimulus-induced facilitation. It is concluded that facilitation is a result of transmitter release, possibly not acetylcholine.

Herpes virus infections in patients with neoplastic disease. Diagnosis and therapy

Herpes viruses are among the most common and troublesome opportunistic pathogens infecting patients with neoplastic diseases. The recent development of partially effective and relatively nontoxic antiviral agents offers promise for the prophylaxis or therapy of these infections in high-risk groups. Vidarabine and acyclovir have shown efficacy in several herpes virus infections and are now licensed in the United States. Alpha interferon may also be useful in the prophylaxis or early therapy of certain herpes virus infections. Newer antiviral agents and combination therapies are under study. Early and rapid diagnosis of such infections is critical to the development of effective therapy.

Comparison of the effectiveness of placebo, clomiphene citrate, mesterolone, pentoxifylline, and testosterone rebound therapy for the treatment of idiopathic oligospermia

Forty-six subfertile men with idiopathic oligospermia were randomly assigned to 6 months of treatment with a placebo, clomiphene citrate (25 or 50 mg/day), mesterolone (100 mg/day), or pentoxifylline (1200 mg/day) or 4 months of testosterone enanthate treatment (100 or 250 mg on alternate weeks). Treatment with the placebo, mesterolone, pentoxifylline, and testosterone rebound therapy did not result in a significant increase in the mean sperm concentration or pregnancy in the partners. Clomiphene citrate at both dosages significantly increased the mean sperm concentration without improving sperm motility or morphology during the 6-month treatment period. Pregnancy rates of 36.4% and 22.2% were observed in partners of men receiving clomiphene citrate 25 mg/day and 50 mg/day, respectively. This study also illustrates the difficulties in identifying suitable patients for and assessing the efficacy of different treatment regimens.

Disseminated tuberculosis in a renal transplant recipient

A case of disseminated tuberculosis in a renal transplant recipient is presented. Tuberculosis can occur in the early postoperative period and is potentially curable. It should be vigilantly looked for in every case of post-transplant infection.

Electro-optic-waveguide frequency translator in LiNbO(3) fabricated by proton exchange

An optical waveguide phase modulator has been fabricated on X-cut LiNbO(3) by using proton exchange in benzoic acid. The phase modulator was operated as a serrodyne optical-frequency translator with shifted-signal to imagesignal discrimination of 52 dB for a 4-MHz frequency shift. The amplitude of the sawtooth driving signal was 10 V peak to peak. Application of a de bias voltage of either polarity was found to cause a substantial reduction in transmitted-light intensity.

The treatment of lymphoblastic lymphoma with antithymocyte globulin

A 20-year-old man with previously treated lymphoblastic lymphoma, a known T-cell disorder, developed progressive disease despite intensive combination chemotherapy with doxorubicin, vincristine, and prednisone. He was subsequently treated with a 21-day course of intravenous antithymocyte globulin at a dose of approximately 15mg/kg per day. This resulted in a marked reduction in lymphadenopathy as determined by physical examination and chest x-ray. Toxicity was limited to minor pruritus which resolved with diphenyldramine and hydrocortisone premedication.

Prognostic significance of posttransfusion hepatitis and chromosomal abnormalities in adult acute nonlymphocytic leukemia

In a retrospective analysis, we studied the effects of posttransfusion hepatitis (non-A, non-B) and chromosomal leukemia upon the overall times of adult patients with acute nonlymphocytic leukemia (ANLL). Seventy-two patients treated at the University of Chicago from 1970 to 1981 were evaluable. The complete remission (CR) rate for the entire group of patients was 33%, and the median survival was 246 days. Twenty-eight patients (39%) developed hepatitis, and 42 (61%) did not. The CR rate of the patients with hepatitis was 54%, and the median survival of this group was 615 days. In comparison, the CR rate for those who did not develop hepatitis was 20%, and their median survival was 136 days (p less than 0.0001). The groups were comparable in terms of race, sex, initial hematologic parameters, chromosomal abnormalities, dates of treatment, chemotherapy treatment programs, and French-American-British (FAB) subtype, but the median age of the patients who did not develop hepatitis was higher than that of the others. Patients who had normal karyotypes and who developed hepatitis had the best overall prognosis (median survival of 738 days). Patients with abnormal karyotypes who failed to develop hepatitis had the shortest survival times (median, 124 days). The group of patients who had the longest survival (median, 1130 days) included those over 40 years old, with posttransfusion hepatitis, and with normal karyotypes. The development of posttransfusion hepatitis and the presence of chromosomal abnormalities appear to be important, but opposite, indicators of overall prognosis for patients with ANLL.